The discovery of the lymphatic system in the 17th century. Part VII: the rise of vascular injection.

In the second half of the seventeenth century, vascular injection was introduced in anatomy for the study of the mechanism of secretion of bodily fluids, a phenomenon into which the lymphatic system plays an important role. Injection became a routine procedure in the second half of the seventeenth century. Reinier de Graaf developed an appropriate syringe to inject liquid into minuscule tubules. He was the first to observe that water injected into seminiferous tubules was partially repelled by transudation to be absorbed by neighbouring lymph vessels. He also injected lymph vessels in and around the uterus and ovaries. His study friend Johannes Swammerdam developed a coloured hardening wax and Ruysch injected coloured hardening wax into vessels and ducts of lymph nodes and excretory glands. Ruysch introduced combined injection - corrosion procedures which resulted in delicate structures, including capillaries. He denied the presence of glandular structures in organs as described by Malpighi, and made blood vessels inclusive lymph vessels agents instead of aids to fluid secretion. His ideas resulted in the concept of the body being completely vascular, a theory which became commonplace in Dutch medical circles. Antony Nuck, the professor in medicine at the Leiden University, injected an amalgam of quicksilver and tin for further evaluation of the lymphatic system. He thought that lymph vessels originated from distal arteries and sustained that the shape of pores in these arteries determined the mechanisms of secretion in secretory glands and in lymph glands. He introduced lymphography.

The discovery of the lymphatic system in the seventeenth century. Part VI: the microscopic discovery of the subtle anatomy.

The discovery of chyle and lymph vessels had furthered the dream of understanding the body's structure and functions. Initially it was thought that chyle was sucked from the intestines through the open mouths of chyle vessels, and that lymph vessels were side branches of arterial end branches. In the second half of the 17th century, microscopy became an adjuvant for research into the subtle anatomy of the lymphatic system. In the present paper, we will focus on its initial use for the study of the structure and function of chyle and lymph vessels, and lymph glands.

The discovery of the lymphatic system in the seventeenth century. Part V: an ode to the nerves.

The English anatomists Francis Glisson and Thomas Wharton introduced theories on the use of recently discovered lymphatic system in the1650s. Their main idea was that membranous tissues were supplied by nerves with a vital fluid produced within nutritive glands, to be carried to the brain and thence from the brain to all membranous tissues, including glands. They stated that the distribution of the vital fluid was based on the similarity between its ingredients and the needs of the recipient tissues, and not on the weight, size or location of pores encountered, as maintained by Descartes. Lymph, a mixture of waste from the consumed vital fluid and moisture transuded by arterial capillaries, was absorbed by the lymphatic vessels to be excreted via excretory glands, or to be diverted to the venous system by reductive glands. The theories of Glisson and Wharton were very soon rejected to be replaced by a mechanistic philosophy, a legacy of Descartes' theories.

The discovery of the lymphatic system in the seventeenth century. Part IV: the controversy.

A controversy over the transport of chyle and lymph started a few weeks after the publication of Pecquet's Experimenta Nova Anatomica. There are records of nearly seventy people who had an active interest in this matter. Three issues were discussed: the purpose of the liver and especially its haematopoietic function, the capacity of the thoracic duct to transport all chyle, and the purpose of the lymph vessels. The controversy over the use of the lacteals and the lymph vessels subsided about 20 years after the first publication of the new theories. In this contribution, we focused on the ideas of William Harvey, since his ideas were close to the real configuration of the lymphatic system, and on the peculiar anatomical set-up of Louis De Bils (ca 1624-1669), an obscure French-Flemish non-professional anatomist, who was the initiator of a heated controversy in the Netherlands with his original ideas.

The discovery of the lymphatics in the seventeenth century. Part iii: the dethroning of the liver.

Around 1650, the thoracic chyle duct and the serous lymph vessels were discovered nearly simultaneously in four different places on the European continent. The new theory was that all ingested fluid, digested food, and serous lymph liquid were drained towards the subclavian veins, and then to the heart where they was mixed with and transformed into blood, which had been the supposed function of the liver. None of the discoverers proposed a valuable alternative function for the liver. Bile formation and filtration of serum from the blood to carry it through lymph vessels to the chyle sac (cysterna chyli) were the only remaining possible liver functions. The liver was dethroned from its presumed function as blood-forming organ with an epitaph starting with the words 'Stay, Wayfarer, Enclosed in this tomb is he who entombed very many'.

The discovery of the lymphatic system in the seventeenth century. Part II: the discovery of Chyle vessels.

In the seventeenth century, opportunities to discover chyle came about through the revival of vivisection. Gaspare Aselli discovered chyle vessels in a living well-fed dog in 1622. He introduced the term 'lacteals' or milky veins. According to Aselli, the lacteals passed through a mesenteric gland which he called 'pancreas'. The 1627 edition of Aselli's booklet was the start of a 'lymphomania', which led to the dissection and vivisection of hundreds of animals, with the University of Leiden being the clear leader in this field. The prominent researchers in Leiden were Jacobus Sylvius and Johannes Walaeus, who performed diverse experiments to support Harvey's theories on systemic circulation, and to find out the correct anatomy and physiology of lacteals and mesenteric glands. Another centre of excellence was Padua, where Veslingius and Wirsüng introduced the idea of the prominent role of the 'real pancreas', and its duct in the transformation of digested food into clear chyle. The idea of the transport of chyle to the liver was an additional support for Galen's theories regarding the function of the liver. Nevertheless, as time went on, there were fewer and fewer believers in Galenic doctrine.

The discovery of lymphatic system in the seventeenth century. Part I: the early history.

The early history of lymphatic anatomy from Hippocrates (ca. 460-377 B.C.) to Eustachius (1510-1574). The presence of lymphatic vessels and lymph nodes was reported by ancient anatomists without any accurate knowledge of their true functions. Lymph nodes were described as spongy structures, spread over the whole body for the support of vulnerable body parts. Digestion was explained as being the resorption of clear chyle from digested food by the open endings of chyle vessels. The first insights into the place of lymphatic components within nutrition emanated from the medical school of Alexandria (fourth century B.C.) where vivisection was a common practice. Herophilus and Erasistratus described mesenteric veins full of clear liquid, air or milk. For Galen of Pergamum, (104-210) mesenteric lymph nodes also had a nutritional function. He described three different types of mesenteric vessels, namely, the arterial vessels, for the transport of spirituous blood to the intestines; the venous side branches of the portal vein, for the transport of nutritive blood from the liver to the intestines; and small vessels, from the intestines to the mesenteric lymph nodes (serous lymph vessels?). According to Galen, chyle was transported via the above-mentioned mesenteric venous vessels from the intestines to the portal vein and liver, where it was transformed into nutritive blood. This doctrine would be obliterated in the seventeenth century by the discovery of systemic circulation and of the drainage of chyle through a thoracic duct to the subclavian veins.

Carotid Bifurcation Resection and Interposition of a Polytetrafluorethylene Graft (BRIG) for Carotid Disease: A Retrospective Study of 153 Consecutive Procedures.

BACKGROUND: Carotid endarterectomy (CEA) is the gold standard for treatment of carotid artery stenosis. CEA can be challenging, even technically impossible. Prosthetic carotid bypass grafting is a proven and safe alternative when CEA is hazardous. An alternative technique that is prosthetic carotid bifurcation resection and interposition of a polytetrafluorethylene graft (BRIG) is described in this article. METHODS: In our Department of Vascular Surgery, between January 2007 and October 2014, 103 BRIG procedures were performed. The outcome of conventional CEA and patients treated by the BRIG procedure were compared. Within the same period of time 50 CEA procedures (32.7%) were performed. Morbidity, mortality, and postoperative restenosis were compared. RESULTS: The 30-day mortality was 1% for the BRIG group and 0% in the CEA group (P value, 0.4839). The 30-day stroke rate was 1.9% for the BRIG group and 0% in the CEA group (P value, 0.3222). One patient died in the early postoperative period from acute myocardial infarction. A total of 13 (8.5%) patients died during follow-up, none of which were surgery related. Median follow-up was 29.1 months. There was a statistically higher restenosis rate in the CEA group compared with the BRIG group (16.0% vs. 1.9%, P value, 0.0053). Other complications were comparable. Mean operating and clamping time were significantly shorter in the BRIG group. CONCLUSIONS: BRIG appears to be a safe and feasible surgical alternative to CEA. The technique allows for shorter operating time, shorter clamping time, and appears to result in lower restenosis rates. Complication rates seem to be comparable to CEA. Prospective, randomized controlled trials on this topic are needed. To perform bilateral procedures, a bifurcation graft should be created to revascularize both the internal and external carotid artery.

Analysis of renal cell carcinoma with subdiaphragmatic macroscopic venous invasion (T3b).

OBJECTIVE: To review our institutional experience of surgery for renal cell carcinoma (RCC) with subdiaphragmatic macroscopic venous invasion (T3b) and to assess variables associated with cancer-specific survival (CSS), as the stratification of RCC with venous involvement (T3b and T3c) is subject to debate. PATIENTS AND METHODS: We retrospectively reviewed the hospital records of patients who underwent a radical nephrectomy with resection of subdiaphragmatic tumour thrombus (T T) between October 1990 and May 2006. The log-rank and Cox uni- and multivariate regression analysis were used to evaluate predictive factors for CSS. RESULTS: In all, 101 cases were identified. In the N0M0 group, univariate Cox regression analysis confirmed that ipsilateral adrenal gland invasion, Mayo Clinic level of T T, histological subtype and fat invasion were significantly associated with worse CSS. In multivariate Cox regression analysis, only Mayo Clinic level of T T was an independent predictor for CSS. In the subgroup with renal vein involvement only, the median CSS was not reached. In the subgroups with level I, II and III T T involvement, the median CSS was 69, 26 and 21 months, respectively. In the N+ and/or M+ group, only tumour size and type were independent predictors of CSS, while the level of T T was not. Radical nephrectomy yielded poor results with a median CSS of 13 months. CONCLUSION: The Mayo Clinic level of T T is an independent prognostic predictor for CSS in non-metastatic T3b RCC. We strongly support the need for re-classification of the currently applied 2002 Tumour-Node-Metastasis staging system, which in its present form does not discriminate between levels of subdiaphragmatic venous invasion.