1

HEARTY WELCOME TO MY BELOVED TEACHERS

2

JOURNAL CLUB

Dr Suresh Managutti PG in Anatomy

SDM Medical College Dharwad

22ndash 12ndash 2011

>

3

THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE

BY -- MARIOS LOUKAS etal

Department Of Anatomical Sciences School Of Medicine St Georgersquos

University Grenada West Indies

Journal ndash Clinical Anatomy24807-816 (October 2011)

4

LYMPHATIC SYSTEM

5

bull The study of the lymphatic system has a lengthy history with many notable medical minds making important contributions

bull We now appreciate that this system is an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull A good knowledge of the lymphatic system is clinically important concerning canceroedemasurgery and the immune response

6

bull This article reviews the history of the evolution and discovery of the lymphatic system

bull Clin Anat 24 807 ndash 816 2011

bull Key words history anatomy lymphaticsdissection

7

bull INTRODUCTION bull Along with the circulatory system the lymphatic

system makes up an extensive network of vessels transporting fluid throughout the body

bull These vessels return extravasated fluids from the body to the circulation preventing any excess build up

bull A unique feature of the lymphatic system is a series of lymph nodes arranged in generalized clusters in major confluences of lymphatic drainage

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

2

JOURNAL CLUB

Dr Suresh Managutti PG in Anatomy

SDM Medical College Dharwad

22ndash 12ndash 2011

>

3

THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE

BY -- MARIOS LOUKAS etal

Department Of Anatomical Sciences School Of Medicine St Georgersquos

University Grenada West Indies

Journal ndash Clinical Anatomy24807-816 (October 2011)

4

LYMPHATIC SYSTEM

5

bull The study of the lymphatic system has a lengthy history with many notable medical minds making important contributions

bull We now appreciate that this system is an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull A good knowledge of the lymphatic system is clinically important concerning canceroedemasurgery and the immune response

6

bull This article reviews the history of the evolution and discovery of the lymphatic system

bull Clin Anat 24 807 ndash 816 2011

bull Key words history anatomy lymphaticsdissection

7

bull INTRODUCTION bull Along with the circulatory system the lymphatic

system makes up an extensive network of vessels transporting fluid throughout the body

bull These vessels return extravasated fluids from the body to the circulation preventing any excess build up

bull A unique feature of the lymphatic system is a series of lymph nodes arranged in generalized clusters in major confluences of lymphatic drainage

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

3

THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE

BY -- MARIOS LOUKAS etal

Department Of Anatomical Sciences School Of Medicine St Georgersquos

University Grenada West Indies

Journal ndash Clinical Anatomy24807-816 (October 2011)

4

LYMPHATIC SYSTEM

5

bull The study of the lymphatic system has a lengthy history with many notable medical minds making important contributions

bull We now appreciate that this system is an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull A good knowledge of the lymphatic system is clinically important concerning canceroedemasurgery and the immune response

6

bull This article reviews the history of the evolution and discovery of the lymphatic system

bull Clin Anat 24 807 ndash 816 2011

bull Key words history anatomy lymphaticsdissection

7

bull INTRODUCTION bull Along with the circulatory system the lymphatic

system makes up an extensive network of vessels transporting fluid throughout the body

bull These vessels return extravasated fluids from the body to the circulation preventing any excess build up

bull A unique feature of the lymphatic system is a series of lymph nodes arranged in generalized clusters in major confluences of lymphatic drainage

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

4

LYMPHATIC SYSTEM

5

bull The study of the lymphatic system has a lengthy history with many notable medical minds making important contributions

bull We now appreciate that this system is an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull A good knowledge of the lymphatic system is clinically important concerning canceroedemasurgery and the immune response

6

bull This article reviews the history of the evolution and discovery of the lymphatic system

bull Clin Anat 24 807 ndash 816 2011

bull Key words history anatomy lymphaticsdissection

7

bull INTRODUCTION bull Along with the circulatory system the lymphatic

system makes up an extensive network of vessels transporting fluid throughout the body

bull These vessels return extravasated fluids from the body to the circulation preventing any excess build up

bull A unique feature of the lymphatic system is a series of lymph nodes arranged in generalized clusters in major confluences of lymphatic drainage

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

5

bull The study of the lymphatic system has a lengthy history with many notable medical minds making important contributions

bull We now appreciate that this system is an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull A good knowledge of the lymphatic system is clinically important concerning canceroedemasurgery and the immune response

6

bull This article reviews the history of the evolution and discovery of the lymphatic system

bull Clin Anat 24 807 ndash 816 2011

bull Key words history anatomy lymphaticsdissection

7

bull INTRODUCTION bull Along with the circulatory system the lymphatic

system makes up an extensive network of vessels transporting fluid throughout the body

bull These vessels return extravasated fluids from the body to the circulation preventing any excess build up

bull A unique feature of the lymphatic system is a series of lymph nodes arranged in generalized clusters in major confluences of lymphatic drainage

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

6

bull This article reviews the history of the evolution and discovery of the lymphatic system

bull Clin Anat 24 807 ndash 816 2011

bull Key words history anatomy lymphaticsdissection

7

bull INTRODUCTION bull Along with the circulatory system the lymphatic

system makes up an extensive network of vessels transporting fluid throughout the body

bull These vessels return extravasated fluids from the body to the circulation preventing any excess build up

bull A unique feature of the lymphatic system is a series of lymph nodes arranged in generalized clusters in major confluences of lymphatic drainage

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

7

bull INTRODUCTION bull Along with the circulatory system the lymphatic

system makes up an extensive network of vessels transporting fluid throughout the body

bull These vessels return extravasated fluids from the body to the circulation preventing any excess build up

bull A unique feature of the lymphatic system is a series of lymph nodes arranged in generalized clusters in major confluences of lymphatic drainage

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

8

bull These clusters are the axillapelvisfemoral canal neck and face and along the course of the descending aorta and inferior vena cava

bull Despite centuries old knowledge and new technological means of mapping and studying lymph drainage the lymphatic system still has esoteric quality associated with it

bull Breakthroughs in oncology during the last half century have shed new light on the clinical significance of this system

bull It also highlights the variation and difficulty of navigating the system in individual patients

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

9

LYMPHATIC SYSTEM

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

10

Lymph nodes of head amp neck

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

11

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

12

LYMPHATIC DRAINAGE OF BREAST

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

13

LYMPHATIC DRAINAGE OF FEMALE PELVIS

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

14

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

15

LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

16

PRE AND PARA AORTIC NODES

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

17

THORACIC LYMPH NODES

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

18

bull Early Discoveriesbull Numerous sources attribute the discovery

of the lymphatic system to a variety of individuals but the general consensus is that the first descriptions were made by the ancient Greeks

bull Among the most prominent physicians of their time Herophilos(300 BC) and Erasistratus(310-250 BC) have been linked to writing treatises about a vessel system resembling the lymphatics

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

19

bull Herophilos bull Erasistratus

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

20

bull Controversy exists regarding whether or not these were actually lymphatic vessels

bull Although surviving documentation of both physicians work is minimal at best both had significant interest in arteries and veins in addition to the contents of these vessels

bull Both doctors were members of the Alexandrian Museum a luxury not afforded too many people of that time

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

21

bull Despite some very insightful ideas about certain medical concepts and practices of time neither was able to correctly identify the physiological functions of the vascular networks with their gross observations on the overall structure of the vessels

bull Famous ancient Greeks Aristotle and Hippocrates made other astute observations

bull In the 4th century BC Aristotle incisively described ldquofibers which take a position between blood vessels and nerves and which contain a colourless liquidrdquo

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

22

bull Aristotle bull Hippocrates

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

23

bull Hippocrates description of the axillary lymph nodes in 400 BC was ldquovessels containing white bloodrdquo

bull Another prominent is worth noting for his contribution to the understanding of the lymphatic system

bull Galen of Pergamum (AD129-199) contributed a great deal to the study of anatomy particularly dissection with his treatise On Anatomical Procedures

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

24

AXILLARY LYMPH NODES

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

bull Under Roman law the dissection of human cadavers was forbidden so Galenrsquos specimens were animals

bull He systematically dissected starting with bones stating ldquothey were like the walls of the houserdquo and wrote meticulous accounts of what he saw

bull He described the mesenteric lymph nodes and lacteal vessel containing chyle

bull Paul of Aegina (AD 607-690) was a renowned surgeon best known for compiling the vast medical encyclopedia Medical Compendium in Seven Books 25

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

26

bull Galen of Pergamum

bull Paul of Aegina

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

27

bull Paul described the tonsils as well as performing and reporting the first tonsillectomy in 625 AD

bull It is likely that it was during his tonsillectomy procedures that he encountered and detailed infected lymph nodes in the lower cervical region

bull 16th ndash 17th Century Discoveriesbull Specific elucidations of the lymphatic

systems went unfulfilled for many centuries

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

28

TONSILECTOMY

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

29

bull As human cadaver dissection became more common the lymphatic system drew greater attention and more mention in the discourses on human anatomy

bull Italian anatomists in the 16th century revealed more about lymphatics through dissection of human cadavers

bull Nicola Massa (1499ndash1569) a Venetian anatomist was a critic of Galenrsquos work claiming that he could not have postulated about a human anatomy without having taken a knife to it and observed it directly

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

30

bull Massarsquos book Liber Introductions Anatomiae (1536) was a hands on investigation of the human body and through these dissections he observed the renal lymphatic vessels

bull Although the function of these lymphatic vessels was still unknown they continued to be source of interest

bull Gabriello Falloppio (1523-1562) of Modena was appointed in 1551 as the chair of anatomy and surgery department at the University of Padua

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

31

bull Much of his work involved the head particularly the ear and the reproductive organs most notably the Fallopian tubes (uterine tubes) which bear his name

bull He mentions a mesenteric ldquoveinrdquo containing ldquoyellow matterrdquo in his works which may have been an early description of a lacteal

bull Other notable contributions made by Italians during this time include those of Marco Aurelio Severino and Marcello Malpighi

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

32

bull Widely regarded as the founder of microanatomy and the first histologist Marcello Malpighi (1628ndash 1689) was the first to observe the capillaries linking the arteries and veins in the lungs

bull In terms of lymphatic anatomy he described the conglobate glands (nodes) lying along the course of the lymphatics

bull Marco Aurelio Severino was a celebrated surgeon in Naples who performed radical mastectomies including axillary dissection

bull This was later proven to be a wise course when Jean Louis Petit (1674-1760) an outstanding French surgeon showed the spread of mammary cancer to the axillary lymph nodes

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

33

bull Spread of cancer along the lymph system was first described by Henri Francois LeDran (1685-1770)

bull In the mid 16th century documented observation of the ldquovena alba thoracisrdquo first appeared following observations of animal dissections

bull Eustachius is widely credited as being the first to discover and name this milky colored duct in 1552 after observing it in horse dissection

bull Eustachius noted the presence and course of this duct but was unable to determine where it terminated

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

34

bull No real advancements were made for many decades after Eustachius lsquo observations

bull The next breakthrough came in the mid 17th century when Gasparo Asellirsquos (1581-1626) work was first published

bull Aselli was a professor of anatomy and surgery in Pavia and on 23 July 1622 he first observed what he later named ldquolacteal vesselsrdquo while dissecting a live dogrsquos abdomen

bull This discovery was as noted by Aselli in his own manuscript made almost completely by accident

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

35

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

36

bull The dog had been fed immediately before being opened up and Asellirsquos intention was to observe the diaphragm when he noticed a fine network of lightly colored vessels

bull Some of the vessels were punctured with milky white fluid emanating out

bull Aselli noted that he originally thought the vessel was a nerve and only investigated further upon seeing the peculiar fluid ooze

bull Aselli followed up his work for the next week dissecting other dogs in both fed and unfed states documenting all he could of this new ldquofourth mesentery vesselrdquo

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

37

bull He named his findings veiue albae aut lacteae ldquoveiuerdquo from their similarity to veins in structure and the absence of pulsation ldquoalbaerdquo to distinguish them from vessels carrying blood and ldquolacteaerdquo for the milk like fluid they contained

bull Asellirsquos descriptions were mainly of anatomical significance only

bull His writings never went beyond describing the structure and course of the vessels tracing them from the mesentery of the gut

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

38

CISTERNA CHYLI

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

39

bull He also noted the presence of valves within the lacteal vessels and surmised them to prevent backflow but stated little else on the matter

bull He noted very little about the function of the vessels as a whole past his (mistaken) opinion that these vessels carried their contents from the gut back to the liver

bull The glory of his discovery would never be received by Gaspero Aselli as he passed away in 1626 with his work unpublished

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

40

bull Publication of his discovery was thanks to two friends Alexander Tadinus and Senator Septalius both physicians from Milan who were left in charge of Asellirsquos manuscripts

bull Published in 1627 Asellirsquos treatise was not without controversy

bull Debate quickly became heated with several prominent anatomists rejecting Asellirsquos work on the course of these vessels

bull The discovery withstood many broadsides and vigorous research followed to both prove Aselli right and prove him wrong

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

41

bull It took many decades for the next major lymphatic discovery to take place when French physician Jean Pecquet (1624-1674) wrote his treatise describing the cisterna chyli and the thoracic duct

bull Pecquet was a young man who by 1648 all of 26 years old had grown tired of ldquocold and dumb factsrdquo gleamed from nonliving dissections

bull In his 1651 publication ldquoExperimenta nova anatomica quibus ignotum hactenus chyli receptaculum et ab eo per in ramos usque subclavio vasa lactea detegunturrdquo Pecquet stated he desired ldquomore correctrdquo knowledge from living organisms and thus set out on a series of vivisections

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

42

CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

43

bull In one experiment Pecquet removed the heart of a dog and noticed a white liquid mixed with the blood

bull Closer investigation led him to believe it was chyle as previously described by Galen and he traced its origin to a duct that dumped into the subclavian vein

bull The discovery was what we know now as the Thoracic Duct

bull Pecquet continued tracing the duct distally until he identified a ldquoreceptaculumrdquo which received flow from the same lacteals discovered by Aselli

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

44

THORACIC DUCT

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

45

THORACIC DUCT LIGATION

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

46

bull Thus this young man fresh out of medical school was able to prove that all the lacteals emptied into the receptaculum chyli and not the liver

bull As a result the cisterna chyli is remembered today as the receptacle of Pecquet

bull A number of contemporaries of Pecquet made similar (and independent) observations on the thoracic duct

bull Olaus Rudbeck (1630-1702) a professor of anatomy in Uppsala presented his work on the thoracic duct in 1652 amp published his results in 1653

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

47

THORACIC DUCT amp CISTERNA CHYLI

>

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

48

bull Rudbeck presented his experiments to the court of Sweden including direct presentations to Queen Christina who took a great deal of interest in his work even allowing him to do numerous dissections in her presence

bull The honor of the discovery of the termination of the lymphatics is not the sole domain of Rudbeck however

bull An English anatomist and medical director George Joyliffe (1621-1658) is said to have made similar observations during the same period

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

49

bull Francis Glisson (1597-1677) another British anatomist stated that Joyliffe was aware of the existence of lymphatics and their termination in 1650 and had demonstrated them

bull He referred to Joyliffersquos observations in his book Anatomica Hepatis published in 1654

bull Glisson also proposed a theory that the lymphatics performed an absorptive function

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

50

bull A chief rival of Rudbeck was Thomas Bartholin (1616-1680) a member of a highly respected family of physicians and a professor at the University of Copenhagen

bull Bartholin studied under Johann Vesling (1598-1694) at the university of Padua

bull Vesling a German anatomist produced the earliest illustrations of the human lymphatic system and his observations about the thoracic duct which were published in 1634

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

51

bull Vesling no doubt had quite an influence on the work of Bartholin who published his work on serous vessels from different parts of the body in 1653

bull Bartholin was the man who coined the name ldquolymphaticsrdquo for this new network of vessels

bull This work was similar to yet independent of Rudbeck and led to a feud for credit of who discovered the system first despite the fact that history has established that Pecquet indeed deserved the honor

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

52

bull Despite their feud Bartholin and Rudbeck agreed on a number of things including the importance of the lymphatic system in cases of ascites and edema as well as on the wide distribution of lymphatic vessels throughout the body

bull One of Bartholinrsquos students Niels Stensen (1638-1686) was the first to discover the right lymphatic and parotid ducts

bull Interestingly Bartholin was also immensely drawn to medical oddities

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

53

bull Bartholin was a staunch supporter of spontaneous human combustion childbirth by mouth and the medicinal uses of unicorns among other beliefs not yet disproven in the mid 17th century

bull Thankfully for his legacy naming the lymphatic system remains his most recognized accomplishment

bull As the anatomy of the lymphatic system was slowly being discovered and defined scientists began using injections to uncover important aspects of the system

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

54

bull Jam Swammerdam (1637-1680) a Dutch biologist and microscopist used suet and wax injections to discover the lymphatic valves that would come to be known as Swammerdam valves

bull Frederick Ruysch (1638-1731) a Dutch botanist and anatomist also used injected material to describe the morphology and function of the valves in 1701

bull The use of a mercury injection by the Dutch anatomist Anton Nuck(1650-1692) helped illuminate fine lymphatic vessels

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

55

LYMPHATIC VALVES

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

56

HISTOLOGY OF LYMPHATIC VALVE

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

57

bull And microscopic injections and corrosion preparations by the German anatomist Johann Nathanael Lieberkuhn demonstrated the origin of lymphatics in the intestinal villi

bull Another noted discovery in gastrointestinal tract was that of lymph nodules in the mucous membrane of the small intestine these Peyerrsquos patches were named after their discoverer Johann Conrad Peyer(1653-1712) of Switzerland

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

58

LACTEALS IN INTESTINAL VILLI

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

59

bull The explosion of new discoveries in this new field caused much disruption among the Old Guard of anatomists who stood firm in the centuries ndashold teachings of Galen

bull Jean Riolan (1577-1657) a highly respected teacher of anatomy and botany in Paris and a man not unfamiliar with biting sarcasm was quoted to say ldquoEveryone needs to be a discoverer nowadaysrdquo

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

60

bull Riolan was an ultra-conservative in his views of demonstrating and ldquodiscoveringrdquo the teachings of ancient physicians

bull In an ironic twist a pioneering anatomist and doctor had a lengthy and well- documented feud with Riolan that offered a strong dissention in the discoveries of the lymphatic system

bull William Harvey (1578-1657) was credited with possibly the most important scientific discovery of the 17th century

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

61

bull The 1628 publication of his book The Circulation of the Blood put forth numerous ideas which caused quite a stir

bull Among the ideas Harvey purported were the idea that the heart pumped blood through its own unique network of vessels

bull And that the arteries contained ldquoblood and blood alonerdquo and not the ldquovital spiritsrdquo that teachers of the previous centuries all the way back to Galen had espoused

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

62

bull He also astutely observed the auricles of the atria contracted together just before the ventricles contracted (systole) contradicting Riolanrsquos claim that the two auricles and two ventricles made four independent contractions in time

bull It did not take much time before numerous anatomists including Riolan took up the cause of opposing him

bull Harvey defended his writings with great fervor but responded directly to only one man Riolan who was the topic of not one but two disquisitions

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

63

bull It was against this backdrop that saw Harvey cast his opinion of doubt on the importance of the work of Pecquet and Bartholin

bull In writings dated 1652 Harvey stated that he had observed these lacteals (possibly even before Aselli) but had doubted their importance within the circulation itself

bull Oddly enough he felt the network of lacteals was ldquotoo extensiverdquo to move all the nutrients from the alimentary canal to the circulation

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

64

bull He felt that if the embryo could receive nutrition from the umbilical veins then an adult human could have nutrition delivered to the liver by the mesenteric veins

bull Riolan however supported the work of Aselli maintaining Asellirsquos opinion that the lacteals drained into the liver and chided Harvey for not thinking likewise

bull It is interesting to note that both theories were partly correct as the lacteals absorb fat-soluble nutrients into the circulation while the mesenteric veins drain the remainder of the nutrition to the liver

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

65

bull 18th -19th century discoveriesbull In the decades following the explosion of

discoveries in the middle part of the 17th century little was elucidated about the actual function of the lymphatic system until the research of William Hunter and his associates was published

bull Hunter (1718-1783)was a doctor and professor of anatomy in London

bull He was a confirmed bachelor and no use for raising a family or for monetary gain beyond allowing him to continue academic endeavors

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

66

bull Hunter was also a tireless scholar working diligently in the dissection room on both animals and human cadavers and teaching numerous pupils at the Great Windmill School and Museum which he founded in 1768

bull Hunter began researching the lymphatics or ldquoabsorbent systemrdquo as he preferred to call it in 1743

bull In 1746 he began lecturing to students that lymphatics ldquoare the same as lacteals and that these together constitute one great and general system dispersed throughout the whole body for absorptionrdquo

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

67

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

68

bull Despite his research and volumes of lectures Hunter did not publish any literature on the topic of lymphatics until 1757

bull Williamrsquos younger brother John (1728-1793) joined his older brother in London in 1748

bull The 20 year old john bore little resemblance to his older brother in terms of work ethic

bull He was lazy and not prone to scholarship in any fashion but the young manrsquos natural talent for dissection and supervision from his brother soon ignited a flame with time and maturity turning the younger Hunter into an accomplished surgeon

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

69

bull John went on to out-pace his brother and become one of the most famous surgeons in England

bull History still shines more on John than it did for William with some calling John the ldquoFather of Modern Surgeryrdquo

bull The brothers worked with a variety of techniques including mercury injection to trace the path of the lymphatic vessels

bull Two of William Hunterrsquos former pupils William Hewson(1739-1774) and William Cruikshank collaborated with the Hunters in research on the lymphatics

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

70

bull William Hunter had an aversion to publishing and spent most of his career as a lecturer and teacher

bull It was publications by his brother John with Hewson and Cruikshank that contain the majority of the grouprsquos findings

bull Hewson published in 1768 on the lymphatics of reptiles and fish

bull In this article Hewson cited and praised John Hunterrsquos work in previously describing the lymphatics in birds and crocodiles and maintained that Hunterrsquos discoveries took place ldquomany years prior to his own work in amphibians and fish

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

71

bull Cruikshank published The Anatomy of the Absorbing Vessels in 1786which was a thorough account of all the illustrations of the lymphatic networks up until that point in time and included a mercury injection tracing of the lymphatic drainage of the breast

bull A year after Cruikshank published his work Paolo Mascagni an anatomy professor from Italy published an atlas of lymphatic vessels in humans that was a significant advance over Cruikshankrsquos work

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

72

bull Mascagni also stressed the origins of the lymphatic vessels and how they were completely separate from blood vessels at the tissue level

bull The origin of the lymphatic vessels from tissue spaces was a point of contention between two great anatomists in the late 1770rsquos Johann Friedrich Meckel (1724-1774) and Alexander Monro the Second (1733-1817)

bull Monro studied under Meckel and when Meckel published an article De venis lymphatics Valvulosis describing the origin of the vessels a controversy arose over who had discovered them first

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

73

bull Early opinions held that lymph vessels had open mouths into the tissues

bull The first to dispel this myth was Albert Von Kolliker(1817-1905)

bull The question of how lymph made its way into the lymph vessels persisted for sometime

bull Von Kolliker published his Manual of Human Histology vol 1 in 1854 which contained descriptions of histological investigations on various species including humans

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

74

bull With Von Kolliker asserting that the structure of the lymphatic vessel ldquocorresponds entirely with the blood capillary in occurrence of nuclei on the inner side of the very delicate and structure less membrane and differed from them in being furnished with short jagged processes with prolongationsrdquo

bull Essentially Von Kolliker concluded that lymph capillaries were continuous

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

75

LYMPHATIC CAPILLARY

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

76

FLOW OF LYMPH

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

77

bull A few years after Von Kolliker published his histological observations a German pathologist named Rudolf Virchow(1821-1902) made the first of a series of investigations that looked at lymph nodes as a barrier which serves role in filtering the lymph of unwanted inclusions

bull Virchowrsquos observations revolved around the idea that when a tumor was present in a certain area one could trace drainage from the cancer to the corresponding lymph nodes that are directly downstream

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

78

VIRCHOWrsquoS NODE

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

79

bull Virchow was the first to use the terms lymphoma and lymphosarcoma

bull Starting in 1856 Virchow published the first of several studies on the topic of lymph node involvement in cancer with descriptions of leukemia lymphoma and pseuodoleukemia

bull Virchowrsquos publications never directly referred to these nodes as ldquoSentinel Nodesrdquo but his publications did lay the groundwork for techniques in the biopsy of lymph nodes a century later

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

80

HODGKINS LYMPHOMA

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

81

LYMPHANGITIS

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

82

bull Until the 19th century the question of how lymph was made was left unanswered

bull There was obviously no debate that lymph existed and that the lymphatics carried it throughout the body

bull Carl Ludwig the German physician and physiologist was the first to correctly postulate that lymph was formed as a filtrate of the blood

bull Ludwig maintained that it was formed by differences in the pressure between capillaries and the interstitium causing fluid to leak through the capillary walls into surrounding tissues

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

83

LYMPHANGIOMA

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

84

LYMPHOEDEMA

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

85

bull During this time a few constitutional discoveries were made in regards to the lymphatic system

bull Guillaume Dupuytren (1777-1835) best known for treating Napoleon Bonaparte was the first to identify the presence of fibrin in chyle

bull Later using microscopic techniques and experimentation Johannes Peter Muller(1801-1858) uncovered the chemical and physical properties of lymph and chyle as well as blood

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

86

bull The movement of lymph through its vessels was first described by Arnold Heller in 1869

bull Further studies by Beatrice Carrier in 1926 and Howard Flory in 1927 confirmed his observations

bull Ludwigrsquos work in the mid 19th century laid the foundation for one of the more famous names in the history of the lymphtatics Ernest Starling who made a leap forward in the understanding of the lymphatic system

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

87

bull Whereas Ludwigrsquos work was more mechanistic in nature Starling brought an imaginative and collaborative approach with him to the laboratory

bull His discoveries were wide ranging from discovering secretin to understanding heart lung interactions but it was his experiments in 1896 that made the teaching of his eponymous theory a staple of medical education

bull Starling was able to show the balance between hydrostatic and oncotic pressures between capillaries and tissues that allowed lymph to form

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

88

bull He was able to document predicable changes in lymph flow based on changes in the experimental conditions and furthermore proved that imbalances in lymph formation and absorption lead to edema

bull In their 1941 publication Lymphatics Lymph and Lymphoid Tissue-Their Physiological and Clinical Significance Cecil K Drinker a staunch outspoken supporter of Starlingrsquos brilliance and his colleague Joseph M Yoffey were able to fully prove that significant changes in protein concentration in either the blood or in the tissue could lead to significant changes in lymph formation

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

89

THYMUS

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

90

THYMUS

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

91

LYMPH NODE

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

92

PALATINE TONSIL

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

93

HISTOLOGY OF PALATINE TONSIL

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

94

SPLEEN

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

95

MICRO ANATOMY OF SPLEEN

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

96

bull Drinker and Yoffey(1941) gave physiological proof of Starlingrsquos assumptions that the lymphatic system plays a key role in interstitial fluid and protein balance

bull The importance of the lymphatic system in pathological conditions particularly cancer was touched upon various times throughout the study of the system

bull A brilliant French pathologist Gabriel Andral (1797-1876) was a pioneer in the understanding of blood composition

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

97

bull Based on the relative proportions of four constituents globules fibrin solids and water Andral observed the differences that occurred in healthy subjects and those with disease processes

bull It was Andral who first diagnosed lymphangitis carcinomatosa based on autopsy results

bull Another prominent pathologist Thomas Hodgkin (1798-1866) published an article in 1832 titled ldquoOn Some Morbid Appearances of the Absorbent Glands and Spleenrdquo that describes a malignant disease that causes enlargement of lymphoid tissue spleen and liver later named Hodgkinrsquos lymphoma

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

98

LYMPHANGITIS CARCINOMATOSA

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

99

bull Bourgery and Jacob in their color atlas in 1831-1854 displayed the lymphatics of the neck thorax abdomen and pelvis

bull Current understandingbull Currently the lymphatic system is recognized

as central to the immune system of the bodybull Not only does it allow for the return of

extravasated fluids it also provides a means for rapid identification of foreign antigens throughout the body

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

100

bull Additionally the cortex of these nodes contains many B lymphocytes which in turn form clonal germinal centers when triggered by an immunological invasion

bull All of these interactions are made possible by the lymphatic system

bull Lymph nodes lying along the lymph vessels effectively trap antigenic substances where they are processed and presented to appropriate immune cells

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

101

bull Lymphography was started in Porto in 1931 by Hernani Monteiro an anatomist to study the lymphatic system in vivo but it was the contribution of Kinmonth (1952) with direct injection of radio opaque contrast that promoted the clinical utilization to study lymphatic disorders

bull The last half of the 20th century saw new clinical significance bestowed upon the lymphatic system in the form of the sentinel lymph node (SLN) theory

bull It was originally observed in human patients that lymphatic drainage of the abdominal cavity went to specific ldquogland sentinelsrdquo

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

102

LYMPHANGIOGRAPHY

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

103

bull A SLN is the first node draining from a primary tumor and it is the node most likely to be affected by metastasis

bull The physician who first coined this term was Ernest Gould who published his finding from the examination of biopsies from 28 patients with cancer of the parotid gland

bull Gould et alrsquos article in 1960 described seemingly normal appearing lymph nodes at the junction of the facial and retromandibular vein

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

104

bull Today the lymphatic system is recognized as an essential component of the immune system as well as vital to the maintenance of fluid homeostasis within the body

bull Familiarity of the impact of the lymphatic system is clinically important concerning cancer edema surgery and the immune response

bull By understanding how knowledge of lymphatics evolved through history one can understand future challenges and breakthroughs in the field

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

105

bull These investigators were able to show that if the node nearest to the parotid gland was free of cancer then the other nodes of the neck would be free as well

bull The routine application of sentinel node biopsy in melanoma has led to the discovery of several new pathways of lymphatic drainage from different areas of the skin

bull A recent study evaluated the utility of a new dye hemosiderin as a marker for sentinel node identification with encouraging results

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

106

bull The possibility of ldquofalse positiverdquo cells in these SLNs remains a concern

bull Increased knowledge of the lymphatic systems has promise as a powerful tool for future advancesbull CONCLUSION bull The study of the lymphatic system has a

lengthy history with many notable medical minds making important contributions

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107

107

• HEARTY WELCOME TO MY BELOVED TEACHERS
• JOURNAL CLUB Dr Suresh Managutti PG in Anatomy SDM Medi
• THE LYMPHATIC SYSTEM A HISTORICAL PERSPECTIVE
• LYMPHATIC SYSTEM
• Slide 5
• Slide 6
• Slide 8
• LYMPHATIC SYSTEM (2)
• Lymph nodes of head amp neck
• Slide 11
• LYMPHATIC DRAINAGE OF BREAST
• LYMPHATIC DRAINAGE OF FEMALE PELVIS
• Slide 14
• LYMPH NODES OF STOMACH amp UPPER ABDOMINALVISCERA
• PRE AND PARA AORTIC NODES
• THORACIC LYMPH NODES
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Slide 23
• AXILLARY LYMPH NODES
• Slide 25
• Slide 26
• Slide 27
• TONSILECTOMY
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• CISTERNA CHYLI
• Slide 39
• Slide 40
• Slide 41
• CISTERNA CHYLI AND THORACIC DUCT LYMPHANGIOGRAM
• Slide 43
• THORACIC DUCT
• THORACIC DUCT LIGATION
• Slide 46
• THORACIC DUCT amp CISTERNA CHYLI
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Slide 54
• LYMPHATIC VALVES
• HISTOLOGY OF LYMPHATIC VALVE
• Slide 57
• LACTEALS IN INTESTINAL VILLI
• Slide 59
• Slide 60
• Slide 61
• Slide 62
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• Slide 70
• Slide 71
• Slide 72
• Slide 73
• Slide 74
• LYMPHATIC CAPILLARY
• FLOW OF LYMPH
• Slide 77
• VIRCHOWrsquoS NODE
• Slide 79
• HODGKINS LYMPHOMA
• LYMPHANGITIS
• Slide 82
• LYMPHANGIOMA
• LYMPHOEDEMA
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• THYMUS
• THYMUS (2)
• LYMPH NODE
• PALATINE TONSIL
• HISTOLOGY OF PALATINE TONSIL
• SPLEEN
• MICRO ANATOMY OF SPLEEN
• Slide 96
• Slide 97
• LYMPHANGITIS CARCINOMATOSA
• Slide 99
• Slide 100
• Slide 101
• LYMPHANGIOGRAPHY
• Slide 103
• Slide 104
• Slide 105
• Slide 106
• Slide 107