Jesus replies:
"I am going to Rome to be crucified again".
Domine, quo vadis ?
(1602) by Annibale Garracci 1
http://www.sacred-destinations.com/italy/rome-domine-quo-vadis
Outside the city he meets
the risen Jesus and asks him:
“Domine, quo vadis?“
“Lord, where are you going?”
Peter is fleeing Rome.
2 Borislav Penchev - Unitec NZ
Shamim Shaikh - Unitec NZ
Lymphology Quo Vadis?
Part-1
Lymphatic system teaching Lymphatic system history
The fate of lymphology
3
“We performed lymphangiograms in the dark ages…alas”
An NZ MRT role model, researcher and educator stated:
Where is the LS going to?
Is the LS relevant to the Medical Imaging practice?
To learn more, we decided to:
We asked old school MRTs
Content
McCracken & Morris, (2001), New Atlas of Human Anatomy, London, Constable Publishers
4
1) Survey the current LS teaching
2) History of the LS exploration
Methods – personal contacts, phone calls and emails – questionnaire completed in class
Participants – students and staff from various tertiary providers, but predominantly from Unitec NZ
Student N = 321; staff N = 11
Survey carried out and analysed by the authors
5
1. CURRENT ANATOMY TEACHING OF LS
Survey – conducted between 2012 and 2017
Provider LS anatomy teaching time Unitec: MI, Nursing, Osteopathy 10-20 minutes
Fiji Med School 20 minutes
Auckland Med School 30 minutes New Zealand College of
Chiropractic
4 hours
Otago Med School 4-5 hours
Disproportionate influx of “soft social” subjects deprived
“hard” scientific topics from adequate teaching time.
Staff & students from the above institutions
“Curriculum time dedicated to anatomy is decreasing (Patel & Moxham, 2008)
6
“Anatomy teaching is in the midst of a downward spiral”
(Older, 2004)QUESTIONNAIRE
Q1: List four anatomical elements of the LS Q2: List two principle functions of the LS Q3: To study, or not to study the LS ?
Q4: If “YES”, how many hours ? Q5: If “NOT”, why not ?
7
Results
8
Q1: List four anatomical elements of the LS
59 Nursing students - 4 students listed 3 elements - 15 students listed 4 elements 47 Osteopathy students - 6 students listed 3 elements
12.5%
32%
12%
215 Med. imaging students - 18 listed 3 elements - 9 listed 4 elements Participants from Unitec Year Numbers Osteopathy students 1, 2 & 3 47
Nursing student 2 & 3 59 Med. Imaging students 1, 2 & 3 215
321
9
Interesting answers
Q1: List four anatomical elements of the LS
Have not learned it before Have no idea
L. nodes in armpits is all I know Trachea and breasts
Pituitary
Hypothalamus Thyroid gland Kidneys
Adrenal glands Endocrine glands Liver
Pancreas
Lymphatic veins Blood
Veins Arteries
“System of nerves, which send signals
from face to other organs”
And the winner is:
Sorry, forgot the LS
Intercostal spaces
To study the LS system - 296 students = 92.22%
Not to study the LS - 25 students = 7.78%
10
Results
Q3: To study, or not to study the LS ?
Not to study the LS - 25 students = 7.78%
Not to study the LS because:
- Not applicable
- Too difficult to show on radiographic images - Not required for radiographic interpretation - Does not help us take images
- Lymphatics can’t be seen on an X-ray - MRTs don’t need it
- Only CT, MRI, sonographers and mammographers need it - Knowledge is not assessed academically
- We can’t assess or detect the LS in an image Medical
imaging 22=10.23%
Nursing 2 =3%
Osteopathy 1=2%
11
Results
12
“I don’t see what it has to do with bones and radiography.
I have never seen any knowledge of the LS been used in the clinical practice”
Recently an year-2 MI student shared:
Provider Teaching time
Unitec 0 to 15-20 minutes
Fiji Medical School very similar Auckland Medical School 20-30 minutes NZ College of Chiropractic 4 hours
Otago Medical School 4- 5 hours
Results
These students suggested an average of 3.64 hours TO STUDY the LS system - 296 students = 92.22%
13
Content
McCracken & Morris, (2001), New Atlas of Human Anatomy, London, Constable Publishers
14
D
A C D
B
1) Survey the current LS teaching
2) History of the LS exploration
1 st BC - 16 th AD – 1700 “Fruitless” years partially due to Galen’s doctrine
15
2. History of lymphology - five periods
To 5 th BC - “Prehistoric”
5 th - 1 st BC - “Fruitful”
16 th - 17 th AD - “Awakening”
17 th - 18 th AD - “Renaissance”
19 th AD - Today - “Modern”
“... liquid “other than blood”
(Chilky, 1997) Cysterna chyli - Percquet (1622-1674), Bartholini (1616-1680), Rudbeck (1630-1702)
Thoracic duct - Eustachius (1500-1574)
Integrating system of the body - Rudbeck
(Forrester, 1996) Lympha - “Clear spring water” (Latin)
LS in the university curriculum Hunter (1715-1783) and Monroe (1733-1817)
Mascagni (1755-1815) , Cruikshank
Chyle - “juice” , “Peri Adenon” - Hippocrates
(Grotte,1979)
Watery channels - Glisson (1597-1677)
(Forrester, 1996) Milky veins - Aselli (1581-1626)
(Choi, 2012) Immunology and molecular imaging of LS
“white veins” - Herophilus & Erasistratus
(Lord,1968)
Vesalius (1514-1564) - founder of modern anatomy
“De humani corporis fabrica ” - 1543 - Padua
Sappey, Poirier, Cuneo - French
The Golden Age
http://evolution.berkeley.edu/
evolibrary/article/history_02 http://www.gettyimages.co.nz/event/years-since-
the-birth-of-andreas-vesalius-510580389
16
https://en.wikipedia.org/wiki/Gaspare_Aselli#/media/File:Aseli_Bassano.jpg
In 1622, while performing a vivisection on a well fed dog,
The 16 th - 17 th “Golden age”
Gaspar Aselli (1581-1626) - Italian
Aselli published “De lactibus sive Lacteis venis…” in 1627
These remained unnoticed for:
- 18 centuries since described by Herophilus and Erasistratus - 14 centuries since last reported
by Galen
Aselli rediscovered the lacteal vessels.
http://www.vivo.colostate.edu/hbooks/pathphys/digestion/smallgut/absorb_lipids.html
17
18
Aselli’s publication may well be the first to use coloured illustrations for better scientific clarity.
https://www.sophiararebooks.com/pages/books/3940/gaspare-aselli/de-lactibus-sive-lacteis- venis-quarto-vasorum-mesaraicorum-genere-novo-invento-dissertatio/?soldItem=true
http://www.nature.com/ajg/journal/v103/n1s/full/ajg2008669a.html
19
During Aselli’s time - early 17th century digestion was seen as:
http://www.desicomments.com/de si/cartoons/fred-flintstone/page/5/
Aselli thought, that the “milky veins”
empty into the liver.
http://exhibits.hsl.virginia.edu/treasures/francis-glisson-1597-1677/
20
Francis Glisson (1597-1677) - English
Published “De Rachitide” in1650 & “Anatomy of the liver” in 1665, And described the “Watery channels and hepatic lymphatics”
http://fn.bmj.com/content/78/2/F154
21
Jean Percquet (1622-1674) - French
Chyli receptaculum
= cisterna chyli
Thoracic duct, which drains into the venous system at the jugular- subclavian union
http://www.sciencedirect.com/scienc e/article/pii/S0039606000022546
In 1651, he published the discovery of:
= cisterna of Percquet
https://en.wikipedia.org/wiki/Jean_Pecquet
https://blog.lib.uiowa.edu/hardin/2014/08/07/notes-from-the-john-martin-rare-book-room-jean-pecquet/
https://babel.hathitrust.org/cgi/pt?id=ucm.5327360967;view=1up;seq=7 https://www.generalanaesthesia.com/people/thomasbartholin.html
22
Thomas Bartholin (1616-1680)-Dutch
In 1952, he described
cisterna chyli & thoracic duct
in his book “Circulation via the
lymphatic vessels” .
23
https://hagstromerlibrary.ki.se/uploads/images/1225/slideshow.jpg
http://cheap-auto-insurance-in-florida.com/learn-more-about-humanatlas- anatomy/human-atlas-anatomy-wink-books-the-best-there-isofanatomical- by-frank-thoracic-duct-celiac-nodes-subclavian-trunk-lymphatic/
https://babel.hathitrust.org/cgi/pt?id=ucm.5327360967;view=1up;seq=7
24
Olaus (Olof) Rudbeck (1630-1702) - Swedish
Drew the entire LS
https://hagstromerlibrary.ki.se/books/16113 https://en.wikipedia.org/wiki/Olaus_Rudbeck
Diagram by
Rudbeck - 1656
https://hagstromerlibrary.ki.se/books/16113
25
suggested, that similarly to the nervous and the endocrine systems,
the LS is an integrating system
of the entire body. (Forester, 1996)
Rudbeck
2 6
Cisterna chyli is located:
- at level T12 - L2
- between aorta and IVC The cisterna receives
- two lumbar trunks - intestinal trunks
- descending thoracic and hepatic trunks - renal & suprarenal trunks
Thoracic duct:
- length - 38 to 45 cm, diameter - 3-5 mm
- through aortic hiatus ascends in the posterior mediastinum between aorta and azygos vein - from T5 gradually inclines to the left
- runs posterior to the left subclavian artery
- joins the left subclavian / jugular vein with a valve
McCracken & Morris, (2001), New Atlas of Hu Anatomy, London, Constable Publishers
A B C
By 1650 it was known that:
27
https://www.pulsus.com/scholarly-articles/azygos-ladder-and-looped-thoracic-duct--a-case-report.html
28
McCracken & Morris, (2001), New Atlas of Human Anatomy, London, Constable Publishers
What was not clear yet
was the LS of
29
McCracken & Morris, (2001), New Atlas of Huma Anatomy, London, Constable Publishers
Niels Steensen (1638-1686) - Danish
Founder of
modern geology
Why not an
anatomists too?
A bishop
https://www.ncbi.nlm.nih.gov/pubmed/20559086 https://en.wikipedia.org/wiki/Nicolas_Steno
Right lymphatic
duct
30
https://plasticsurgerykey.com/lymphedema/
SVC
CSF
31
1 st BC - 15 th AD – 1500 “Fruitless” years
History of lymphology
To 5 th BC - “Prehistoric”
5 th - 1 st BC - “Fruitful”
16 th - 17 th AD - “Awakening”
17 th -18 th AD-“Renaissance”
19 th AD - Today “Modern”
LS in the university curriculum
W. Hunter (1715-1783) and A. Monroe (1733-1817)
Injecting of mercury into lymphatics
P. Mascagni (1755 - 1815), Cruikshank
32
https://en.wikipedia.org/wiki/William_Hunter_(anat omist)#/media/File:William_Hunter_(anatomist).jpg
The
Hunter-Monro controversy
https://en.wikipedia.org/wiki/Alexander_Monro_(secun dus)#/media/File:Alexander_Munro_secundus.jpg
Scotish - Alexander Monro Jr. (1733 1817)
The LS gained popularity, when two famous 18 th century anatomists included the LS in the curriculum of the universities they worked for.
English - William Hunter (1715-1783)
https://en.wikipedia.org/wiki/John_Hunter_(surgeon )#/media/File:John_Hunter_by_John_Jackson.jpg
John Hunter
https://en.wikipedia.org/wiki/William_Hunter_(a natomist)#/media/File:Hunterw_table_12.jpg
http://neurology.mhmedical.com/data/
books/1477/rop_ch29_f001.png https://pbs.twimg.com/medi
a/CaEyzQLUsAEqGFQ.jpg
33
In 1771, Mascagni introduced the dyeing of lymphatics with mercury
http://library.uthscsa.edu/2014/03/a-landmark-in-anatomical- illustration-paolo-mascagni-and-the-lymphatic-system/
Mascagni mapped, named and described ALL principal lymphatic vessels and nodes
Paolo Mascagni - (1755 - 1815) - Italian
- lymphatics originate
from interstitial space & serous cavities
https://en.wikipedia.org/wiki/Paolo_Mascagni
Published by Pazzini Carli, Siena, 1787
This technique enabled him to determine, that:
- lymphatics are related to absorption
https://pictures.abebooks.com/MILESTONEBOOKS/18765559530_5.jpg
34
.
https://nz.pinterest.com/pin/409053578625829100/
Published in 1787
35
In the same 1787 year
Cruikshank located the breast - axilla l. pathway using mercury.
But, once again, the LS was
forgotten for almost a century until
, when M. Ph. C. Sappey (1810-1896)
published the mercury based superficial lymphatic drainage of the torso.
1874
https://en.wikipedia.org/wiki/Marie_Philibert_Constant_Sappey
36
Cutaneous lymphatics by Sappey
https://clinicalgate.com/diseases-of-the-lymphatic-circulation/
Surgical cutaneous incisions to be
parallel to the lymphatic
vessels
Watershed L2
https://www.researchgate.net/publication/304358392_Lymphosome_conce pt_Anatomical_study_of_the_lymphatic_system_Lymphosome_Concept
37
A 1903 diagram of the breast lymphatics by
Poirer & Cuneo as seen in the Gray’s Anatomy.
https://www.researchgate.net/figure/5803842_fig8_FIG-8-Poirier-and- Cuneo-O-s-summary-diagram-of-the-breast-lymph-drainage-26-This
Poirier & Cuneo
By the end of the 19 th - beginning of 20 th century
the LS mapping was completed on a macroscopic level.
19 th AD - Today - “Modern” Immunology & molecular imaging
Sappey, Poirier, Cuneo – all French
http://www.neonatology.org/classics/hess1922/hess.3.html
EMBRYOLOGICAL DEVELOPMENT
Jugular lymphatic sacs
Cisterna chyli Starts at 5 th week
(Heart beats at 3 rd week)
Mesenteric lymphatic sac
Iliac lymphatic sacs
https://healtheappointments.com/chapter-2-abdomen-essays/13/
38
39 UPPER
LATERAL
This theoretical basis is used for injection of dye and/or isotope for sentinel node mapping and biopsy.
https://www.researchgate.net/publication/5803842 The Lymphatic Anatomy of the Breast and its Implications for Sentinel Lymph Node Biopsy A Human Cadaver Study
https://www.researchgate.net/figure/236277213_fig4_Figure-5-The- lymphatic-vessels-white-arrow-ran-along-the-thoracodorsal-vein-black https://www.researchgate.net/publication/236277213_Map
ping_Superficial_Lymphatic_Territories_in_the_Rabbit
40
Your current teaching needs updating
.
Lymphology
Quo Vadis?
41
REFERENCES:
Chilky, A., (1997). Who Discovered the Lymphatic System? Lymphology, 30: p. 186-193.
Lord, R.S., (1968). The White Veins: Conceptual Difficulties in the History of the Lymphatics Medical History, Cambridge Journals Medical History12(2): p. 174-184.
Grotte, G., (1979). The Discovery of the Lymphatic Circulation. Acta Physiologica Scandinavica. Supplementum,. 463: p. 9-10.
Choi, I., Lee, S., Hong, Y.K., (2012). The New Era of the Lymphatic System: No Longer Secondary to the Blood Vascular System.
Cold Spring Harbor Perspectives in Medicine,. 2(4): p. 1-23.
Forrester, J.M., (1996). English manuscripts of Francis Glisson: from Anatomia hepatis 1654. Medical History, 40(1): p. 121.
Miller, J.F., (2002). The Discovery of Thymus Function and of Thymus-derived Lymphocytes. Immunological reviews, 185: p. 7-14.
Witte, M.H., Witte, C. L., (1995). Epilogue: beyond the sphere of knowledge in lymphology. Clinics in Dermatology, 13(5): p. 511-514.
Pal, I., Ramsay, J. D., (2011) The Role of the Lymphatic System in Vaccine Trafficking and Immune Response. Advanced Drug Delivery Reviews,. 10(63): p. 909-922.
Patel, K.M., Moxham, B.J., The relationships between learning outcomes and methods of teaching anatomy as perceived by professional anatomists. Clin Anat. 2008 Mar;21(2):182-9. doi: 10.1002/ca.20584.
Dillaman, R.M., Roer, R. D., Gay, D. M., (1991). Fluid movement in bone: theoretical and empirical. Journal of Biomechanics, 24: p.
163-177.
Weller, R.O., Galea, I., Carare, R. O., Minagar, A., (2010). Pathophysiology of the lymphatic drainage of the central nervous system:
Implications for pathogenesis and therapy of multiple sclerosis. Pathophysiology, 17(4): p. 295-306.
IIiff, J., Wag, M., Liao, Y., Plogg, B.A., Peng, W., Gundersen, G. A., Benveniste, H., Vates, G. E., Deane, R., Goldman, R., Nagelhus, E. A., Nedergaard, M., (2012) A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid β. Science Translational Medicine. 15(4): p. 147ra111 .
The Lymphatic Anatomy of the Breast and its Implications for Sentinel Lymph Node Biopsy: A Human Cadaver Study . Retrieved from:
https://www.researchgate.net/publication/5803842 The Lymphatic Anatomy of the Breast and its Implications for Sentinel Lymph Node Biopsy A Human Cadaver Study
Netter, F., (2006) Atlas of Human Anatomy, 4 th edition
Older, J., Anatomy: a must for teaching the next generation. Surgeon. 2004 Apr;2(2):79-90.
Natale, G., Bocci, G., Ribatti, D., (2017) Scholars and scientists in the history of the lymphatic system. Journal of Anatomy. DOI:
