HEARTY WELCOME TO MY BELOVED

TEACHERS

JOURNAL CLUB

Dr. Suresh. Managutti.

PG in Anatomy
SDM Medical College Dharwad

22 12 2011
2

THE LYMPHATIC SYSTEM :

A HISTORICAL PERSPECTIVE
BY -- MARIOS LOUKAS et.al
Department Of Anatomical Sciences,
School Of Medicine, St Georges
University, Grenada , West Indies.
Journal Clinical Anatomy
24:807-816 (October 2011)
3

LYMPHATIC SYSTEM

 The study of the lymphatic system has a

lengthy history ,with many notable medical
minds making important contributions.

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.
A good knowledge of the lymphatic system is
clinically important concerning
cancer,oedema,surgery and the immune
response.
5

 This article reviews the history of the

evolution and discovery of the lymphatic
system.
Clin. Anat. 24: 807 816, 2011

Key words: history; anatomy;

lymphatics;dissection

 INTRODUCTION
Along with the circulatory system, the lymphatic
system makes up an extensive network of
vessels transporting fluid throughout the body.
These vessels return extravasated fluids from
the body to the circulation, preventing any
excess build up.
A unique feature of the lymphatic system is a
series of lymph nodes, arranged in generalized
clusters in major confluences of lymphatic
drainage .
7

 These clusters are the axilla,pelvis,femoral

canal, neck and face, and along the course of
the descending aorta and inferior vena cava.
Despite centuries old knowledge and new
technological means of mapping and studying
lymph drainage, the lymphatic system still has
esoteric quality associated with it.
Breakthroughs in oncology during the last half
century have shed new light on the clinical
significance of this system.
It also highlights the variation and difficulty of
navigating the system in individual patients.
8

LYMPHATIC SYSTEM

Lymph nodes of head & neck

10

11

LYMPHATIC DRAINAGE OF BREAST

12

LYMPHATIC DRAINAGE OF FEMALE PELVIS

13

14

LYMPH NODES OF STOMACH & UPPER

ABDOMINALVISCERA

15

PRE AND PARA AORTIC NODES

16

THORACIC LYMPH NODES

17

 Early Discoveries
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.
Among the most prominent physicians of
their time, Herophilos(300 B.C.) and
Erasistratus(310-250 B.C.) have been linked
to writing treatises about a vessel system
resembling the lymphatics.
18

 Herophilos

Erasistratus

19

 Controversy exists regarding whether or

not these were actually lymphatic vessels.
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.
Both doctors were members of the
Alexandrian Museum a luxury not afforded
too many people of that time.
20

 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.
Famous ancient Greeks, Aristotle, and
Hippocrates made other astute observations.
In the 4th century B.C., Aristotle incisively
described fibers which take a position
between blood vessels and nerves and which
contain a colourless liquid.
21

 Aristotle

Hippocrates

22

 Hippocrates description of the axillary

lymph nodes in 400 B.C. was, vessels

containing white blood
Another prominent is worth noting for his
contribution to the understanding of the
lymphatic system.
Galen of Pergamum (A.D.129-199)
contributed a great deal to the study of
anatomy, particularly dissection with his
treatise On Anatomical Procedures.
23

AXILLARY LYMPH NODES

24

 Under Roman law ,the dissection of human

cadavers was forbidden, so Galens
specimens were animals.
He systematically dissected, starting with
bones, stating they were like the walls of
the house and wrote meticulous accounts
of what he saw.
He described the mesenteric lymph nodes
and lacteal vessel containing chyle.
Paul of Aegina (A.D. 607-690) was a
renowned surgeon best known for
compiling the vast medical encyclopedia
25
Medical Compendium in Seven Books.

 Galen of
Pergamum

Paul of Aegina

26

 Paul described the tonsils, as well as

performing and reporting the first
tonsillectomy in 625 A.D.
It is likely that it was during his
tonsillectomy procedures that he
encountered and detailed infected lymph
nodes in the lower cervical region.
16th 17th Century Discoveries
Specific elucidations of the lymphatic
systems went unfulfilled for many
centuries.
27

TONSILECTOMY

28

 As human cadaver dissection became

more common, the lymphatic system drew
greater attention and more mention in the
discourses on human anatomy.
Italian anatomists in the 16th century
revealed more about lymphatics through
dissection of human cadavers.
Nicola Massa (14991569), a Venetian
anatomist ,was a critic of Galens work
claiming that he could not have postulated
about a human anatomy without having
taken a knife to it and observed it directly.
29

 Massas book, Liber Introductions Anatomiae

(1536) was a hands on investigation of the
human body and through these dissections he
observed the renal lymphatic vessels .
Although the function of these lymphatic
vessels was still unknown, they continued to
be source of interest.
Gabriello Falloppio (1523-1562) of Modena
was appointed in 1551 as the chair of anatomy
and surgery department at the University of
Padua.
30

 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.
He mentions a mesenteric vein containing
yellow matter in his works, which may have
been an early description of a lacteal.
Other notable contributions made by Italians
during this time include those of Marco
Aurelio Severino and Marcello Malpighi.
31

 Widely regarded as the founder of microanatomy

and the first histologist, Marcello Malpighi (1628
1689) was the first to observe the capillaries linking
the arteries and veins in the lungs.
In terms of lymphatic anatomy , he described the
conglobate glands (nodes) lying along the course of
the lymphatics.
Marco Aurelio Severino was a celebrated surgeon in
Naples, who performed radical mastectomies,
including axillary dissection.
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.
32

 Spread of cancer along the lymph system was

first described by Henri Francois LeDran (16851770).
In the mid 16th century, documented observation
of the vena alba thoracis first appeared
following observations of animal dissections.
Eustachius is widely credited as being the first to
discover and name this milky colored duct in
1552 after observing it in horse dissection .
Eustachius noted the presence and course of this
duct, but was unable to determine where it
terminated.
33

 No real advancements were made for many

decades after Eustachius observations.
The next breakthrough came in the mid 17th
century ,when Gasparo Asellis (1581-1626) work
was first published.
Aselli was a professor of anatomy and surgery in
Pavia and on 23 July 1622 ,he first observed what
he later named lacteal vessels while dissecting
a live dogs abdomen.
This discovery was, as noted by Aselli in his own
manuscript , made almost completely by
accident.
34

35

 The dog had been fed immediately before being

opened up, and Asellis intention was to observe
the diaphragm when he noticed a fine network of
lightly colored vessels .
Some of the vessels were punctured , with milky
white fluid emanating out.
Aselli noted that he originally thought the vessel
was a nerve, and only investigated further upon
seeing the peculiar fluid ooze.
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
fourth mesentery vessel.
36

 He named his findings veiue albae aut

lacteae, veiue from their similarity to veins
in structure, and the absence of pulsation;
albae to distinguish them from vessels
carrying blood; and lacteae, for the milk like
fluid they contained.
Asellis descriptions were mainly of
anatomical significance only.
His writings never went beyond describing
the structure and course of the vessels,
tracing them from the mesentery of the gut.
37

CISTERNA CHYLI

38

 He also noted the presence of valves within

the lacteal vessels , and surmised them to
prevent backflow, but stated little else on the
matter.
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.
The glory of his discovery would never be
received by Gaspero Aselli as he passed away
in 1626 with his work unpublished.
39

 Publication of his discovery was thanks to two

friends , Alexander Tadinus and Senator
Septalius, both physicians from Milan, who were
left in charge of Asellis manuscripts .
Published in 1627, Asellis treatise was not
without controversy.
Debate quickly became heated, with several
prominent anatomists rejecting Asellis work on
the course of these vessels.
The discovery withstood many broadsides and
vigorous research followed to both prove Aselli
right and prove him wrong.
40

 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.
Pecquet was a young man, who by 1648, all of 26
years old, had grown tired of cold and dumb facts
gleamed from nonliving dissections.
In his 1651 publication Experimenta nova
anatomica, quibus ignotum hactenus chyli
receptaculum, et ab eo per in ramos usque subclavio
vasa lactea deteguntur, Pecquet stated he desired
more correct knowledge from living organisms ,
and thus set out on a series of vivisections.
41

CISTERNA CHYLI AND THORACIC DUCT

LYMPHANGIOGRAM

42

 In one experiment, Pecquet removed the heart

of a dog, and noticed a white liquid mixed with
the blood.
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.
The discovery was what we know now as the
Thoracic Duct.
Pecquet continued tracing the duct distally until
he identified a receptaculum, which received
flow from the same lacteals discovered by Aselli.
43

THORACIC DUCT

44

THORACIC DUCT LIGATION

45

 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.
As a result, the cisterna chyli is remembered today
as the receptacle of Pecquet.
A number of contemporaries of Pecquet made
similar (and independent) observations on the
thoracic duct.
Olaus Rudbeck (1630-1702), a professor of
anatomy in Uppsala, presented his work on the
thoracic duct in 1652 & published his results in
1653.
46

THORACIC DUCT & CISTERNA CHYLI

47

 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.
The honor of the discovery of the termination of
the lymphatics is not the sole domain of
Rudbeck, however.
An English anatomist and medical director,
George Joyliffe (1621-1658) is said to have made
similar observations during the same period.
48

 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.
He referred to Joyliffes observations in his
book Anatomica Hepatis, published in 1654 .
Glisson also proposed a theory that the
lymphatics performed an absorptive
function.
49

 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.
Bartholin studied under Johann Vesling
(1598-1694) at the university of Padua.
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.
50

 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.
Bartholin was the man who coined the name
lymphatics for this new network of vessels.
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.
51

 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.
One of Bartholins students, Niels Stensen
(1638-1686) was the first to discover the
right lymphatic and parotid ducts.
Interestingly, Bartholin was also immensely
drawn to medical oddities.
52

 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.
Thankfully, for his legacy, naming the
lymphatic system remains his most recognized
accomplishment.
As the anatomy of the lymphatic system was
slowly being discovered and defined, scientists
began using injections to uncover important
aspects of the system.
53

 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.
Frederick Ruysch (1638-1731), a Dutch
botanist and anatomist, also used injected
material to describe the morphology and
function of the valves in 1701.
The use of a mercury injection by the
Dutch anatomist Anton Nuck(1650-1692)
helped illuminate fine lymphatic vessels.

54

LYMPHATIC VALVES

55

HISTOLOGY OF LYMPHATIC VALVE

56

 And microscopic injections and corrosion

preparations by the German anatomist
Johann Nathanael Lieberkuhn demonstrated
the origin of lymphatics in the intestinal villi.
Another noted discovery in gastrointestinal
tract was that of lymph nodules in the
mucous membrane of the small intestine;
these Peyers patches were named after their
discoverer, Johann Conrad Peyer(1653-1712)
of Switzerland.
57

LACTEALS IN INTESTINAL VILLI

58

 The explosion of new discoveries in this

new field caused much disruption among
the Old Guard of anatomists, who stood
firm in the centuries old teachings of
Galen.
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,
Everyone needs to be a discoverer
nowadays.
59

 Riolan was an ultra-conservative in his views

of demonstrating and discovering the
teachings of ancient physicians.
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.
William Harvey (1578-1657) was credited
with possibly the most important scientific
discovery of the 17th century.
60

 The 1628 publication of his book The

Circulation of the Blood put forth numerous
ideas, which caused quite a stir.
Among the ideas Harvey purported were the
idea that the heart pumped blood through
its own unique network of vessels.
And that the arteries contained blood and
blood alone and not the vital spirits that
teachers of the previous centuries all the
way back to Galen had espoused.
61

 He also astutely observed the auricles of the atria

contracted together just before the ventricles
contracted (systole), contradicting Riolans claim
that the two auricles and two ventricles made
four independent contractions in time.
It did not take much time before numerous
anatomists, including Riolan, took up the cause
of opposing him.
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.
62

 It was against this backdrop that saw Harvey

cast his opinion of doubt on the importance
of the work of Pecquet and Bartholin.
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.
Oddly enough, he felt the network of
lacteals was too extensive to move all the
nutrients from the alimentary canal to the
circulation.
63

 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.
Riolan, however, supported the work of Aselli,
maintaining Asellis opinion that the lacteals
drained into the liver, and chided Harvey for not
thinking likewise.
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.
64


18th -19th century discoveries
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.
Hunter (1718-1783)was a doctor and professor of
anatomy in London.
He was a confirmed bachelor and no use for
raising a family or for monetary gain beyond
allowing him to continue academic endeavors.
65

 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.
Hunter began researching the lymphatics or
absorbent system as he preferred to call it, in
1743.
In 1746, he began lecturing to students that
lymphatics are the same as lacteals and that
these together constitute one great and
general system dispersed throughout the
whole body for absorption.
66

67

 Despite his research and volumes of lectures,

Hunter did not publish any literature on the topic
of lymphatics until 1757.
Williams younger brother John (1728-1793)
joined his older brother in London in 1748.
The 20 year old john bore little resemblance to
his older brother in terms of work ethic.
He was lazy and not prone to scholarship in any
fashion, but the young mans 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.
68

 John went on to out-pace his brother and become

one of the most famous surgeons in England.
History still shines more on John than it did for
William, with some calling John the Father of
Modern Surgery.
The brothers worked with a variety of techniques,
including mercury injection to trace the path of
the lymphatic vessels .
Two of William Hunters former pupils, William
Hewson(1739-1774) and William Cruikshank
collaborated with the Hunters in research on the
lymphatics.
69

 William Hunter had an aversion to publishing and

spent most of his career as a lecturer and teacher.
It was publications by his brother John, with
Hewson and Cruikshank that contain the majority
of the groups findings.
Hewson published in 1768 on the lymphatics of
reptiles and fish.
In this article, Hewson cited and praised John
Hunters work in previously describing the
lymphatics in birds and crocodiles and maintained
that Hunters discoveries took place many years
prior to his own work in amphibians and fish.
70

 Cruikshank published The Anatomy of the

Absorbing Vessels in 1786,which 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.
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 Cruikshanks work.
71

 Mascagni also stressed the origins of the

lymphatic vessels and how they were completely
separate from blood vessels at the tissue level.
The origin of the lymphatic vessels from tissue
spaces was a point of contention between two
great anatomists in the late 1770s Johann
Friedrich Meckel (1724-1774) and Alexander
Monro the Second (1733-1817).
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.
72

 Early opinions held that lymph vessels had

open mouths into the tissues .
The first to dispel this myth was Albert Von
Kolliker(1817-1905).
The question of how lymph made its way into
the lymph vessels persisted for sometime.
Von Kolliker published his Manual of Human
Histology, vol. 1 in 1854, which contained
descriptions of histological investigations on
various species, including humans.
73

 With Von Kolliker asserting that the

structure of the lymphatic vessel
corresponds 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 prolongations.
Essentially, Von Kolliker concluded that
lymph capillaries were continuous.
74

LYMPHATIC CAPILLARY

75

FLOW OF LYMPH

76

 A few years after Von Kolliker published his

histological observations, a German
pathologist named Rudolf Virchow(18211902) 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.
Virchows 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.
77

VIRCHOWS NODE

78

 Virchow was the first to use the terms

lymphoma and lymphosarcoma.
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.
Virchows publications never directly referred
to these nodes as Sentinel Nodes, but his
publications did lay the groundwork for
techniques in the biopsy of lymph nodes a
century later.
79

HODGKINS LYMPHOMA

80

LYMPHANGITIS

81

 Until the 19th century, the question of how lymph

was made was left unanswered.
There was obviously no debate that lymph
existed and that the lymphatics carried it
throughout the body.
Carl Ludwig, the German physician and
physiologist, was the first to correctly postulate
that lymph was formed as a filtrate of the blood.
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.
82

LYMPHANGIOMA

83

LYMPHOEDEMA

84

 During this time, a few constitutional

discoveries were made in regards to the
lymphatic system.
Guillaume Dupuytren (1777-1835), best
known for treating Napoleon Bonaparte, was
the first to identify the presence of fibrin in
chyle.
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.
85

 The movement of lymph through its

vessels was first described by Arnold Heller
in 1869.
Further studies by Beatrice Carrier in 1926
and Howard Flory in 1927 confirmed his
observations.
Ludwigs 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.
86

 Whereas Ludwigs work was more mechanistic

in nature, Starling brought an imaginative and
collaborative approach with him to the
laboratory.
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.
Starling was able to show the balance between
hydrostatic and oncotic pressures between
capillaries and tissues that allowed lymph to
form.

87

 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.
In their 1941 publication Lymphatics, Lymph, and
Lymphoid Tissue-Their Physiological and Clinical
Significance, Cecil K. Drinker, a staunch, outspoken
supporter of Starlings 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.
88

THYMUS

89

THYMUS

90

LYMPH NODE

91

PALATINE TONSIL

92

HISTOLOGY OF PALATINE TONSIL

93

SPLEEN

94

MICRO ANATOMY OF SPLEEN

95

 Drinker and Yoffey(1941) gave physiological

proof of Starlings assumptions that the
lymphatic system plays a key role in interstitial
fluid and protein balance.
The importance of the lymphatic system in
pathological conditions, particularly cancer, was
touched upon various times throughout the
study of the system.
A brilliant French pathologist, Gabriel Andral
(1797-1876) was a pioneer in the
understanding of blood composition.
96

 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 .
It was Andral, who first diagnosed lymphangitis
carcinomatosa based on autopsy results.
Another prominent pathologist, Thomas Hodgkin
(1798-1866) published an article in 1832 titled On
Some Morbid Appearances of the Absorbent Glands
and Spleen that describes a malignant disease that
causes enlargement of lymphoid tissue, spleen and
liver, later named Hodgkins lymphoma.
97

LYMPHANGITIS CARCINOMATOSA

98

 Bourgery and Jacob in their color atlas in 1831-1854

displayed the lymphatics of the neck, thorax,
abdomen, and pelvis.

Current understanding
Currently, the lymphatic system is recognized
as central to the immune system of the body.
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.
99

 Additionally, the cortex of these nodes contains

many B lymphocytes, which in turn form clonal
germinal centers when triggered by an
immunological invasion.
All of these interactions are made possible by
the lymphatic system.
Lymph nodes lying along the lymph vessels
effectively trap antigenic substances where
they are processed and presented to
appropriate immune cells.
100

 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.
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.
It was originally observed in human patients that
lymphatic drainage of the abdominal cavity went to
specific gland sentinels
101

LYMPHANGIOGRAPHY

102

 A SLN is the first node draining from a primary

tumor, and it is the node most likely to be
affected by metastasis.
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.
Gould et al.s article in 1960 described
seemingly normal appearing lymph nodes at the
junction of the facial and retromandibular vein.
103

 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.
Familiarity of the impact of the lymphatic system
is clinically important concerning cancer, edema,
surgery, and the immune response.
By understanding how knowledge of lymphatics
evolved through history, one can understand
future challenges and breakthroughs in the field.

104

 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.
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 .
A recent study evaluated the utility of a new
dye, hemosiderin, as a marker for sentinel node
identification, with encouraging results .
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 The possibility of false positive cells in these

SLNs remains a concern.
Increased knowledge of the lymphatic systems
has promise as a powerful tool for future
advances.

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