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  • 1. WiltlingcrTextbook of Dr. VodelersManual Lymph DrainageVolume I: Basic Course
  • 3. Textbookof Dr. VoddersManual Lymph Drainag,eVolume 1: Basic CourseBy GUnther Wittlinger t and Hildegard WittlingerPreface by Dr. phil. Emil Vodder tTranslation revised and edited by Robert H. Harris H. N . D.(Appl. BioI., U. K.)With 17 illustrations, 1 table and 1 portrait3rd revised editionc£AV])Karl F. Haug Publishers . Heidelberg
  • 4. CIP·Tilelaurnahme der DeuIS(:hen BibliolhekTextbook or Dloc10 Ir "odders manual lymph drainage. -Heidelberg: Haug. DI. Ausg. u.d.T.: Lchrbuch der manuellen Lymphdrainage nach Dr.Voddcr Frtiher u.d.T.: Introduction to D[oclolrVodder"s manual lymph dr.:linageVol. I. Basic Coursclby GuntherVittlinger u. HildcgardWittlinger. 1l1lnsl. by Roben H. Harris. -3rd ed. -1900 ISBN 3-7760-1156-4 E: WillI inger, Gunther I MitverLITIlis translation was revised and edited by Robert /-I. lIarris H. N. D. (Appl. BioI.. u. K.),who is a registered massage therapist in lOronlo. .muda and certificd tcacher of Dr.Vodders Munual Lymph Drainage tcchnique.Toronto. anada )ilJluary 1990 1982 Karl F. Ilaug Verlag GmbH & Co .. HeidelbergAile Rechte. insbesondere die der Obcrsclzung in fremdc Sprachcn, vorbchallcn. KcinTcil dieses Buchcs darf ohne schriftliche Gcnehmigung dcs Vcrlagcs in irgendeincr Fonn­durch I>hotokopic. Mikrofilm odcr irgcndcin undcrcsVcrfahrcn-rcproduzicrl oder in cinevon Maschincl1, insbesondere von DatcnverarbcitungslIlaschinen. verwcndbare SprachcUbcrlnlgcn oder UbcrselZl werden.All rights reserved (including those of tnlnslalion into fl1rcign languages). No p:lrI of thisbook nt:ly be reproduced in any form -by phOioprint, microfilm, or any other means -nortr::tn�llljlled or translated illlo a machine language without ..... ritten permission from thepublishers.2nd edition 19853rd edition 1900litle-No. 2156· ISBN 3-nfIJ-1156-4Typeset and printcd by: I>rogressdruck GmbH. 6720 Speycr
  • 5. Dedicated to our esteemed teachersEstrid Vodder and Emil Vodder t
  • 7. Table of ContentsForeword to the first english edition . . . . . . . . . . . . . . . . 10Foreword to the second revised english edition . . . . . . . . . . 18Course of study in manual lymph drainage (MLD) for beauticians . 19Course of study in manual lymph drainage (MLD) for health careprofessionals and therapists . . . . . . . . . . 19The history of manual lymph drainage (MLD) . . . . . . . . . . 20A) THEORETICAL SECTION 1. Mode of action of manual lymph drainage 25 a) Effect on the autonomic nervous system 25 b) Effect on the reflex pathways 27 c) Immunological effect 28 The immune system 28 Humoral immunity . 29 Cellular immunity . . 30 d) Effect on the smooth muscles of the blood vessels and lymph angions (anatomy and function) 32 e) Drainage effect . . . . . . . 35 2. Connective tissue . . . . . . . . 36 a) Structure and characteristics 36 b) Function . . . . . . . 38 c) Connective tissue cells 40 3. Transport systems in the body 40 a) Water balance . 40 b) Circulation . 42 c) Lymph system . 43 d) Lymph nodes . 43 e) Anatomy of the large lymph vessels 46 f) Summary of the transport systems in the body 48 4. Substance transport . 49 a) Molecular motion 49 b) Diffusion . . . . 49 c) Substance transport in the connective tissue . 50 d) Osmosis . . . . . . . . . . . . . . . . . . . 50 7
  • 8. 5. Effect of MLD on blood capillaries and connective tissue . 51 a) Structure and function of blood capillaries 51 b ) The Starling equilibrium 52 c) Dehydrating effect of MLD via the blood capillaries and lymph vessels 53 6. The significance of optimal massage pressure . 54 7. Inertial mass 55 8. Steel and rubber elasticity 55 9. The lymph system 57 a) Lymphatic watersheds 57 b) Mechanisms of the initial lymph vessels 58 c) Protein circulation and transport 61 10. Equilibrium and balance as a goal of massage 65 a) Bathtub 65 b) Fluid equilibrium 66 c) Equilibrium in natural healing methods 67 1 1. Oedema forms 67 a) Lymphostatic oedema . 69 b) Lymphodynamic oedema 69 c) Legs with varicose veins . 71 d) Safety-valve insufficiency 71 12. Cosmetic indications 71 13. Indications for physiotherapy . 73 14. Relative contraindications 73 15. Absolute contraindications 74 16. Treatment guidelines 74 Excursus in the cosmetic field . 74 Inflammations 75 Acne 76 Cellulitis / Adiposis 77 Lipoedema 79 Toothaches 79 Consideration of outside temperature 808
  • 9. Iontophoresis . . . . . . . . . . . . . . . . . . 80 Stress and Dr. Vodders manual lymph drainage 81 Scars . . . . . . . . . . . . . . . . . . . . . . 82B) PRACTICAL SECTION 1. Massage technique . 85 a) Stationary circles 85 b) Pump technique . 85 c) Scoop technique . 86 d) Rotary technique 86 e) Frequency of massage 86 f) Environmental conditions for optimal therapy 87 g) Basic principles . . . . . . . . . . . . . . . . 88 Sequence of manipulations l. Treatment of the neck 89 If. Treatment of the face 92 Ill. Treatment of the anns 94 IV. Treatment of the legs 97 V. Treatment of the nape 100 VI. Treatment of the back 101 VII. Treatment of the buttocks 104 V III. Treatment of the chest . . 105 IX. Treatment of the abdomen 109 X. Therapeutic manipulations - special techniques . . . . . . 1 11 2. Dr. Vodder on the technique of manual lymph drainage 1 12C) APPENDIX Lymph drainage - A new therapeutic method serving cosmetic care 1 17 Bibliography 122 9
  • 10. Foreword The following preface was written by Dr. Emil Vodder, creator of theManual Lymph Drainage method. Although my wife and I completed the elaboration of the MLD meth­od in France during the years 1932-1936, we were unable to write a bookabout it until forty years later. We have been travelling around Europefor many years now, holding lectures and courses to explain the struc­ture and functions of the lymph system by means of drawings and manu­als. Needless to say, the scientific world was not yet ready for our fin­dings and would not accept our hypotheses and empirical evidence. Thelymph system was an unknown factor in the field of physical therapy, anunexplored and dangerous "no-mans-land". It was considered inadvisa­ble to massage the lymphatic nodes, since it was thought that the treat­ment would spread bacteria and viruses. Children with swollen nodes inthe neck, for example, were said to have "scrofulosis" and were opera­ted on to remove the affected nodes. Appendicitis and spleen operationswere also carried out without considering that, in so doing, the defencemechanisms of the body could be impaired -an hypothesis that later re­search proved to be true. Doctors in Ancient Greece knew about the lymph system in the intes­tines, i.e. the chylous vessels, which resemble white chains of pearls andcontain the milkywhite chylous sap. Herophilus wrote that "vesselsemerging from the intestines enter a number of gland-like bodies andnot the portal vein". These gland-like bodies are our lymph nodes. In the Middle Ages anatomical research was regarded as sinful; scien­tific discoveries were therefore few during this period. In the Renais­sance, however, a large number of important findings emerged. Manyschools of anatomy were established, for example in Salerno, Bologna,Padua, Montpellier, Paris, Leyden, Copenhagen and Uppsala. In 1662,in Padua an Italian by the name of Aselli displayed the lymph vessels ina dogs intestines. He called them "chyliferi", -shimmering milky-whiteveins. Six years later in London William Harvey published his excitingdiscovery, namely that the blood makes a complete circuit in the body.Two students, Jean Pecquet in Montpellier (1647) and Olaf Rudbeck inSweden, discovered the thoracic duct in dogs. Rudbeck was a Renais­sance genius who founded the still existing "Theatrum Anatomicum" inUppsala. In 1653 he published "Nova exercitatio anatomica" and called10
  • 11. the newly discovered vessels "vasa serosa" and the lymph nodes "glan­dulae aquosae". As a favourite of Queen Christina of Sweden, he hadthe honour of demonstrating his anatomical findings to the royal court. In July 1637 a young Dane, Thomas Bartholin, was studying at theUniversity of Leyden in Holland. His scientific research was facilitatedby the existence of the "Theatrum Anatomicum" in Leyden, a library, abotanical garden and a hospital overflowing with patients. Up to thattime only lunatic asylums and hospitals for plague victims had been builtin Northern Europe. BarthoLin studied AseLLis lymph vessels and learn­ed how to inject gum resin and indigo into the vessels to render them vis­ible. Over a period of ten years he visited many countries, studyinglanguages and natural sciences. When he finally returned to Denmarkhe had become a renowned scientist and took over the newly built "The­atrum Anatomicum" in Copenhagen. He was the first to describe theentire lymph system. He wrote four papers in Latin, dedicated to KingFrederick III, describing the lymph system as a natural process that puri­fies the body and regulates irritation, swelling and oedema. In "VasaLymphatica", L652-1654, he describes his findings on lymph vessels andnodes in humans. No researcher had as yet used any special term for thelymph fluid. Bartholin called the vessels "vasa Iymphatica" and theircontent "lymph" -clear water from the Latin "limpidus", meaning clear. Twenty years later in Schaffhausen, lohan Conrad Peyer describedthe intestinal lymph aggregations, now named "Peyers Patches". Re­search was continued in many countries during the following centuries.Lymphology, however, the science of lymph and tissue fluids, was notdeveloped until recently. The water content of the body should be stud­ied as a whole because all organs and organic systems are intimately con­nected within it. The ground substance is ubiquitous in the body, although it varies ac­cording to its milieu, as described by Professor Hugo Grau in Dr. ZiLchsinstructive work, "Lymph System and Lymphatismus". This book ishighly recommended to all students interested in lymph research and im­munology (Munich, 1963). Very early in our studies we were of the conviction that the humanbody should be regarded as a whole. We were inspired by the writings ofCLaude Bernard, Alexis Carrel and CeciL Drinker, who convinced us ofthe importance of the omnipresent lymph system in the body. AlexisCarreL, the father of modern organ transplants, confirmed this view 11
  • 12. when he received the Nobel Prize in 1912 for his research on the cultiva­tion of living cells. This was an exciting period, since we foresaw whatthe future held for us. Carrels classic experiment proved that the cells ina chickens heart stayed alive if the lymph fluid was continuously renew­ed. Later we based our method of lymphatic regeneration of the skin onthis principle. We were certain that the lymph fluid was the source of mi­raculous hidden forces. But despite great strides made in the field of bio­logy, the lymphocytes retained their secret until in the middle of this cen­tury it was discovered that the nuclei of the lymphocytes contain the life­giving substance desoxyribonucleic acid (DNA), which is the prime sub­stance of life and the vehicle of genetic traits in all organisms. Research on the lymph system reached its peak when immunologistsestablished that lymphocytes produce antibodies to protect the bodyagainst viruses and infections. It is of interest to note that thirty years agoone of the first lymph researchers in the United States, Professor CecilDrink er, prophesied that the lymph system would be recognised as themost important organic system in humans and animals. We lived eleven years of our youth in the inspiring atmosphere ofFrance - five years on the sunny Riviera and six busy years in Paris. Bystudying everything that we could find about lymph and by putting whatwe learned into practice we were able to develop hypotheses which havelong since been confirmed by researchers. One day a client came to our physical therapy institute in Cannes fortreatment of a nose and throat infection, migraine and blemished, oilyskin. As usual, I closed my eyes while I palpated the hard, swollen, cervi­cal lymph nodes. I suddenly imagined a nasal sinus covered with shim­mering lymph vessels. In my mind I also saw their drainage focussed inthe neck, the lymph node chains that act as a natural draining system forthe skin, mucosa and meninges, i.e. for all the organs and nodes in thehead and neck. As far as I know, this complex had never previouslybeen interpreted as a natural separate drainage apparatus for the entirehead region. I asked myself whether obstruction in the severely swollen lymphnodes could be the underlying cause of these different ailments. Werethe impurities of the skin and the catarrh of the mucous membranes theresult of the malfunction of the lymph nodes? Would it be possible to un­block the drainage system by treatment with appropriate massage tech­niques? Had I just discovered a universal therapy to cure the lymphatic12
  • 13. syndrome? This hypothesis has since been substantiated a thousand tim­es over by such treatment, which has no side-effects whatsoever. My pa­tient was completely cured of all his ailments after ten facial massagesusing gentle rotary pumping movements ·over the lymph node chains.Nor did the ailments recur. Did the lymph have undreamt-of healingpowers? No doubt! In 1933 we moved to Paris where we contin�ed our research, espe­cially with regard to the anatomical and physiological aspects of thelymph-vessel system. Professor Rouviere had just published his book"Lanatomie des Lymphatiques de IHomme" ("Anatomy of the Lym­phatic Vessels in Man"). Alexis Carrel had written an invaluable bookcalled "Der Mensch - das unbekannte Wesen" ("Man - the Unknown"),and most important was the huge atlas by the anatomist Phil. Sappeywhich contained a collection of very beautiful copperplate engravings,which we used a great deal during our courses in manual lymph drai­nage. (Phil. Sappey: "Description et Iconographie des Vaisseaux Lym­phatiques Consideres chez IHomme et les Vertebres, Paris 1885 - "Des­cription and Iconography of the Lymph Vessels in Man and the Verte­brates".) In 1936 we succeeded in compiling a simple systematic list of massagemovements, using our intuition and extensive practical experience. Anentirely new set of massage techniques was necessary. There had to becircular pumping and draining movements with a pressure of less than 30mm Hg (now called torrs) so as to prevent blood congestion. We em­ployed gentle stationary circles on the lymph nodes, an area that no onehad previously dared to massage, palpating with the tips or the entirelength of the fingers. Massaging was always in the direction of the clavi­cular fossa, the terminus of all lymph pathways in the body. The methodwas conceived not only for facial treatment, i.e. for cosmetic and pre­ventive measures, but also to cure illnesses. Our therapeutic treatmentoften produced surprising and rapid results. Positive effects were alwaysobtained if correct, slow and rhythmic movements were employed,whether we were treating the patient for skin rejuvenation, haematomascaused by accidents, eczema, varicose veins or ulcerous legs. It was nowtime to present our findings to the public. An important exhibition tookplace in Paris in the spring of 1936 with a theme which particularly attrac­ted me: Sante et Beaute ("Health and Beauty"). It was a great success,and the newspapers reported on "lymph drainage - a revolutionary skin 13
  • 14. treatment". I had written an article in French which appeared in the Pa­risian journal "Sante pour Tous" ("Health for Everyone") for which Iwas coeditor. It was later translated into Danish and Swedish. After spending eleven instructive years in France, we were forced toreturn to our home town of Copenhagen at the outbreak of the SecondWorld War. We began again and founded a new MLD institute which wehave now been running for 25 years. As we had already called the newfield "Iymphology", we called the students that we trained "lymph thera­pists." But it was not until the fifties that other countries showed any interestin our work. Then we were invited to give lectures and courses in variouscountries, which we have now been doing for the last 20 years. We havepersonally trained thousands of students from Europe and abroad. Wealso employ assistants and a fulltime staff who continue to teach our ori­ginal method and lifes work - "Dr. Yodders Manual Lymph Drai­nage". What progress has science made in the last decade? Modern develop­ments such as the electron microscope, tracer methods, computers andmacromolecular chemistry have also provided new insight into aspectsof the lymph system for which no logical explanation had been offeredtill then. For example, researchers discovered the vital substance DNAin the lymphocyte nucleus, which forms the very basis of life and is thevehicle of genetic traits in all cells. It contains the blueprints for all the tissues of our body, as already pro­grammed in the fetus. A healthy lymph system promotes healthy bodytissues and body functions. The lymph system is not only the source ofgood health, it also guards against infection. Research on the lymph system, formerly known as the "neglectedchild of medicine", reached its summit recently with elucidation of theimmune system. Renowned Iymphologists and immunologists haveproved that the lymphocytes are responsible for the production of anti­bodies to combat viruses and infections ranging from innuenza to can­cer. At the very beginning of our research my wife and I interpreted thebody as a whole and thus regarded the lymph system as a source of life.The lymph system that originally developed from the primordial soup isuniversal and combines the macrocosmos and microcosmos in us. It re­presents the omnipresent living environment of the body because all14
  • 15. nutrients and vital substances must flow throughout the lymph interspa­ces by way of a "transit stretch" to the cells. The term lymph has taken on a broad meaning in modern lymph the­rapy. As far as our technique is concerned it covers not only the intersti­tial lymph that carries the nutrient fluid to the cells but also indirectly thefluid circulating in the protoplasm of trillions of·cells. It should be notedthat some Iymphologists insist that the connective tissue fluid is not thesame as the lymph fluid. On the other hand, it is said that the lymph fluiddevelops in the connective tissue. One thing, however, is certain: the lymph system not only serves toclean tissues through the drainage, but is also a protection and defensemechanism and carries out vital functions. Just as the red blood corpuscles act as vehicles to transport oxygen andcarbon dioxide, the lymph fluid carries the lymph-obligatory load (i.e. amixture of vital substances and toxins) back to the blood stream. Thelymph contains nearly all plasma-protein constituents necessary to thecells as building substances and nutrients as well as vitamins, hormones,and destroyed cells (waste products) e.g. as a result of haematomas orother injuries. None of these large molecules can pass through the ve­nous walls; their transport by the lymph system is therefore essential tolife. For this reason it is clear that the lymphocytes carry building substan­ces to the cell tissues and that effective use of manual lymph drainage cangreatly accelerate the process of building new cells. Millions of lympho­cytes are continuously being produced in the lymph tissues (in the pala­tine and pharyngeal tonsils, the spleen, the lymph nodules and Peyerspatches. ) Recent research findings show that an average of 35 billionlymphocytes enter the blood every day through the terminal ducts thatempty into large veins in the lower part of the neck. This number can in­crease up to as much as 562 billion during periods of stress. Professor Collard of Brussels convincingly demonstrated the forwardmovement of lymph during manual lymph drainage treatment. He illu­strated this by means of a color film using a contrast medium. Classicalmassage techniques, on the other hand, had no drainage effect whatso­ever. Professor Kuhnkes investigations lead him to the same conclu­sions. He demonstrated that a pressure of 30 mm Hg was correct andalso necessary to remove proteinacious tissue swelling (oedema). Re­search carried out by Casley Smith in Australia showed that normal mas- 15
  • 16. sage techniques are much too forceful to allow drainage in the intersti­tium and may hinder transport (lymph obstruction). The lymph system is even more fascinating as a defence mechanism inthe immune system and represents the most promising research field foryoung investigators today. Many years ago, Professor Olliviero, a re­nowned biologist in Paris, made the following humorous comparison:"Man", he said, "is an amphibian. Even the most beautiful femininebody is no more than an aquarium with 50 liters of lukewarm seawater inwhich trillions of cells live and fight for survival." The unicellular organisms, which originated from the sea, have accu­mulated all essential chemical genetic substances on the endless road ofevolution. In this aqueous environment the amoebas, or rather the lym­phocytes, had to learn as unicellular organisms to protect the "privatesphere". They formed an outer covering or a membrane, so as not to bediluted or destroyed. The chemistry of life was thus protected in thisfashion by the cellular membrane. Evolutions as we know it, could thenbegin. The existence of cells in the primordial ocean was naturallyaccompanied by the need for food. The cells that knew best how to ex­ploit the energy resources flourished and gained supremacy over the lessefficient cells. The best and purest source of nutrients was found in thecells themselves - harmful substances and toxins came from the exterior.Gradually some cells joined together - strength in numbers -and the in··separable cells survived. The chemical processes that take place in the body were the best andmost ingenious that mother nature could have developed. These con­cern the substances that regulate metabolism, i.e. sugar and fat that pro­vide energy, amino acids that form proteins and phospholipids thatmake up cellular membranes. Man has evolved unremittingly and has emerged the victor of a three­billion-year-long fight for survival. However, the original struggle that began in the primordial oceanwhen the first cell turned against its own kind has never ceased despiteculture, mercy and altruism. Today we are living as always on a seabed of bacteria and viruses. Themost vicious warriors measure only seven microns in diameter and yetare our deadliest foes. These tiny enemies carry out silent lightning at­tacks. Viruses and bacteria that enter a cut finger or the mucous mem­brane can reach the brain cells seconds later. For this very reason our im-16
  • 17. mune system maintains a huge arsenal of white blood corpuscles. A per­son weighing 70 kilograms has an average of 26 billion granulocytes andmacrophages (phagocytes) from the bone marrow at the ready. In addi­tion there are other groups of chemical "guards" and microbiological"killer cells". Professor Gowans of Oxford stated in a lecture: "There isno doubt that our ability to survive in an environment full of hostile mi­croorganisms depends on the strength of our huge army of lympho­cytes. " As a preface to this first textbook I have written a retrospective reporton the development of Manual Lymph Drainage (MLD) and have alsoprovided an outline of scientific efforts aimed at disclosing the alI-impor­tant secrets of the lymph system. We express our deep gratitude to Mr.and Mrs. Wittlinger, the directors of the Dr. Vodder School in Walchsee,Tirol, for meeting a long-felt need with this textbookCopenhagen-Bagsvaerd, January 1978 Dr. phil Emil Vodder 17
  • 18. Foreword to the 2nd revised English Edition Rapid scientific progress in the field of lymphology has made it neces­sary to update this textbook on Dr. Vodders Manual Lymph Drainage. We are very happy to note, at the ripe age of 86 and 87, that this bookhas already appeared in English, Spanish, Dutch, Italian and Swedishand is now being translated into French. This shows us that our lifeswork, Manual Lymph Drainage, is gradually gaining followers in manycountries. Everywhere, Lymph Drainage has an almost magical appeal.Unfortunately, though, this demanding massage technique is also prac­ticed by unqualified people - much to the detriment of the method. Alllymph drainage teachers - both young and old - have a duty to meet atleast every other year with our successors and authors of this book in or­der to adapt theory and practice to changing requirements. We must allbear responsibility for preserving Dr. Vodders Lymph Drainage andpreventing it from becoming diluted. Our patients will benefit from ourefforts. That this may always succeed is the heartfelt wish of Dr. EmilVodder and Estrid Vodder.Copenhagen-Bagsvaerd July 198418
  • 19. Course of study in manual lymph drainage (MLO) for beauticians Training in manual lymph drainage comprise the basic, advanced, andreview courses. The basic course is divided into four parts:Part I: treatment of the neck and face.Part 2: treatment of the arms and legs.Part 3: treatment of the nape of the neck, back and loin.Part 4: treatment of the breast and abdomen. Each part is accompanied by a theoretical hour, making a total of 40hours of instruction for the basic course. The advanced course refines the techniques learned in the basiccourse and prepares the student in both theoretical and practical aspectsfor the final examination given at the end of the advanced course. In ad­dition, special practical applications in cosmetics are covered. Upon pas­sing the examination, which is divided into a theoretical and practicalpart, the student receives an internationally recognized diploma that en­tities him or her to practice MLD independently in the fields of healthcare and cosmetics. The advanced course consists of 40 hours of instruc­tion. Review courses, lasting one or two days are offered for improvingtechnique, exchanging practical experience, and extending theoreticalknowledge. Course of study in manual lymph drainage (MLO) for health care professionals and therapists The course of study for therapists lasts a total of four weeks, in whichthree successive therapeutic courses follow the basic course describedabove. After completing the course, the therapist is able to treat thosedisorders indicated for MLD. The diploma awarded to the student uponpassing the examination of the Dr. Vodder School, Walchsee, is interna­tionally recognized. Graduates of the course pledge themselves to voluntary, continuededucation in MLD, as new findings on the effect of MLD and continuouspractical reviews of the manual techniques make this essential. 19
  • 20. Weekend courses are also held for therapists with the aim of promo­ting continued training. Good technique is decisive for therapeutic suc­cess. The Dr. Vodder School, Walchsee, teaches the original method. The history of manual lymph drainage (MLD) In 1932 Dr. Vodder and his wife were working as masseurs in Canneson the French Riviera. The majority of their patients were English whowere there to recover from chronic colds, caused by the damp climate inBritain. The Vodders discovered that all of the patients had swollenlymph nodes in their necks. At that time the lymphatic system was taboofor masseurs - even for physicians. The prevailing view was to take nonote whatsoever of it. I t was regarded as a medical Pandoras box. Vod­der dared to break the taboo and treated the swollen lymph nodes intui­tively and successfully. The colds vanished. Encouraged by these succes­ses, he developed the MLD method as we teach and apply it today. His method was first made known to the public in 1935. His first publi­cation appeared in 1936 in Paris[11. From this time on - for 40 years - heremained active as a masseur, held lectures, gave demonstration treat­ments with his wife and taught courses. Also, the term "manual lymphdrainage" was coined by the Vodders. This gives them the claim as theoriginators. His renown spread. Attracted by these pioneering activities, a growing number of mas­seurs, beauticians and physicians became interested in MLD. This led in1967 to the founding of the "Society for Dr. Vodders Manual LymphDrainage", whose aim was to scientifically substantiate the effect ofMLD and to set up optimal courses of study for the various professionalgroups. In the next chapter, the scientific basis of MLD will be presented withspecial attention given to the question: Can the therapist use MLD? (Forthe therapist the book contains all the subject matter of the basiccourse.) The Society for Dr. Vodders MLD, founded in 1967, was integratedin 1976 into the German Society of Lymphology as the section Thera­peutic Lymph Drainage and Cosmetic Dermatological Lymph Drai­nage. The heritage was assumed by the Society for Dr. Vodders Lymph20
  • 21. Drainage in Walchsee, which was established in 1972. The Dr. VadderSchool founded at the same place teaches the unaltered original method.The goal of this school is to incorporate MLD into the training, and tosupervise the teachers in order to ensure that people benefit from themethod. The objectives of the school are in full accordance with thewishes of Dr. Vadder and his instructions to the authors. · The following chapters do not claim to be complete. They are inten­ded as an aid to the beautician and therapist in understanding the com­plex scientific basis of how MLD works. For this reason we have chosena somewhat simplified approach. 21
  • 23. A) Theoretical Section
  • 25. Mode of action of manual lymph drainage a) EtTect on the autonomic nervous system The diagram to be drawn shows the four ways in which MLD acts onthe body. MLD acts on the autonomic nervous system. This consists ofthe sympathetic nervous system, the day nerve, which makes us activeand allows us to work, and the parasympathetic system, the night nerve,which permits us to rest, sleep, and renew our strength for the next day. These two nerves extend to all parts of the body; that is to say, vessels,muscles, organs, and - especially interesting to the beautician - the skin,and exert an equalizing effect that is vital to the very existence of the or­ganism. Recent findings [93] show that they even branch out into the softconnective tissue. In a healthy person the autonomic nervous system is balanced. Daily .stress, the environment, striving for success are factors contributing tothe fact that many of us no longer possess balanced autonomic systems.As a result, the sympathetic nervous system predominates. MLD, on the other hand, has a stimulating effect on the parasympa­thetic nervous system. This means that after proper application of MLDthe patient becomes calmer, more relaxed some even fall asleep duringtreatment. This effect is desirable, for many women come to the beauti­cian just to enjoy an hour of relaxation. They like to be looked after andattended to, and their pleasure is increased by the effect of MLD. Thereare a number of patients whose disease stems from the fact that they arein a state of disharmony in which the sympathetic system dominates.Hutzschenreuter [48] writes that MLD can have a sympathicolytic effect(ie. calming on the sympathetic system.) MLD is at least one of the pos­sible types of therapies that can successfully be used in these cases. It is therefore essential that the manual techniques be carried out in aslow, monotonous rhythm. If performed too quickly, they will have justthe opposite effect; they will stimulate the patient and make her/him ner­vous. The parasympathetic system has a trophotropic effect; that is, itpromotes growth and recovery and restores strength. These are proces­ses that are characteristic of sleep and cannot be influenced by consciouswill. The causes of muscular hypertension [2] are often of a subconsciousnature. Our conscious mind is subordinate to the motor and sensory 25
  • 26. functions of the body. If the hypertension of many of our clients were notcaused by the subconscious, they could consciously control or influencethe disorder themselves. This, however is not the case. Tn using MLD,we are able to influence muscular hypertension through the autonomicnervous system. Whereas the conscious mind in man is centred in the cerebrum, thesources of unconscious nonphysical stimuli are assumed to be seated inthe autonomic centres of the rest of the brain and the spinal column. Re­flexes that can be triggered by physical manipulation act upon autono­mic centres. One of the great physician masseurs, Dr. H. Marnitz, wrote: [26] Dr. Vodders Lymph Drainage is based on an ingeniously devised, simpleand convincing technique that brings about an acceleration of lymphflow. At the same time, however, a soothing effect on the sensitive nerveendings of the skin is achieved and a certain reflex detonization of theskin.ReHexes A reflex [3] is a response to a stimulus. Nerve cells called receptors arcorgans designed to receive various kinds of stimulus. For example, thereare receptors that respond to light, chemical substances, heat, and me­chanical influences. The receptor converts the stimulus it is designed toreceive into an electrical signal, which it transmits to a nerve cell. Thenerve cell then conveys the signal via axons to the reflex centres. Fromthis switching point the signals are relayed to the respective target or- .gans. For example, when you prick your finger with a needle, the targetorgans are those muscles that pull your finger away. Many reflexes areaccompanied by feelings. The retlexes that are of interest to us are the"fight or flight" reflexes as well as those that induce pleasure. Hard,rough massaging may set off recoil and defence reactions or even flightreflexes. The resulting pain is usually associated with increased muscletension. Feelings of aversion (e.g. anger, fear) accompany these refle­xes. When MLD is properly employed, however, pleasure reflexes are eli­cited. These are accompanied by pleasant sensations (e.g. feelings of af­fection, well being). They lower the basic activity of the muscles and thusexert a relaxing effect.26
  • 27. b) Effect on the reflex pathways [3] The nerves known as nociceptive fibres transmit pain-causing stimulifrom the periphery in the form of action potentials. The word nocicep­tive comes from the Latin nocere (to hurt). If you put a rubber bandaround your wrist, then pull it and let it snap back, you will feel pain. Af­ter some time a red welt appears that swells. We have here all the symp­toms of inflammation: swelling, reddening, pain, and heat. This is the lo­cal response to a pain stimulus, which is received by a nociceptor (painreceptor) and is transmitted in the form of action potential via nocicep­tive fibres, the spinal column, and the brain stem to the cerebrum. Thepain stimulus results from the destruction of cells in the affected area.The breakdown products of the destroyed cells, such as histamine, sero­tonin, and prostaglandins, act on the nociceptive fibres. It is this thatthen produces in us the sensation we call pain. A nociceptive stimulus is received by the appropriate receptor, a noci­receptor, and transmitted by way of nerves to the point of transition tothe next ganglion cell. This transition point is called a synapse. In thiscase the synapse transmits a stimulation. It is excitatory and is able toconvey the excitation to the higher areas of the central nervous system. The nociceptor continues to send action potential to the central ner­vous system as long as it is excited; that is, as long as the cause of the painpersists. Besides nociceptors, there are also touch receptors. These transmitstimuli produced by touch, such as those that are elicited by MLD orstroking. They too transmit these touch sensations by means of actionpotential via nerves to the vertebral column. There they encounter gang­lion cells, whose synapses also have an excitatory function. The stimulusis relayed via axons of the ganglion cell to higher areas of the central ner­vous system, where the agreeable sensation of touch is elicited. Theaxon possesses a collateral; that is, a connection that leads to anotherganglion cell. This ganglion cell is known as an inhibitory cell. Upon be­ing stimulated, it transmits the action potential to the ganglion cell thatis excited by the nociceptor. Together, these two ganglion cells form aninhibitory synapse, which means that any pain signals coming from thenociceptors are inhibited, blocked, even cancelled, whenever the inhibi­tory cell is simultaneously excited. There is, however, one reservation.The touch receptor responds to change in the stimulus, for example, at 27
  • 28. the beginning and at the end of a stroke, but not to the stroke itself.Thus, it is continuously excited by MLD, since the constantly changingpressure applied during MLD brings along a continuous variation in thestimulation. In this way the touch receptors - and thus the inhibitorycells - are continuously excited. In simple terms, this means that precise execution of MLD, which ischaracterized by light, continually changing pressure, activates inhibi­tory cells whose function is to decrease or even eliminate sensations ofpain. c) Immunological effectThe immune system With MLD we treat all lymph nodes that are accessible to our hands.Thus, we treat some of the most important organs of the bodys immunesystem. Nowadays we must familiarize ourselves with various terms ofimmunology, although we might not be able to prove that MLD influen­ces the bodys immunity. "What does the immune system protect?" [22]The immune system distinguishes between "self" and "nonself. In thebody the feature "self" is carried to a large extent by proteins, but alsopolysaccharides and lipids. In the larger molecules of multicellular ani­mals certain chemical groups possess a spatial arrangement that is char­acteristic of the species . This species-specific spatial pattern within themolecule is the genetically coded self feature. It is by virtue of this spe­cial molecular arrangement that every living species claims its unique­ness. It is the function of the immune system to protect this uniqueness. The immune system is directed not only against infectious pathogens,i.e. their virulence, but also against substances that are foreign to thespecies, especially proteins. Only pathogens (bacteria and viruses) that �possess virulence, antigenity, or both will trigger the defence mecha­nisms of the immune system. In addition, the immune system is responsible for getting rid of bodytissue that has no function, as this represents a disturbing influence in theprotein individuality of the organism. The immune system constitutes a vital protective system of the body.Immunity is understood to be the protection we have against a second at­tack of an infectious disease.28
  • 29. Thus, a person contracts measles only once in life because the body isimmune after the disease has abated. Immunity against measles, how­ever, does not protect us against other infectious diseases. This propertyof immunity is known as specificity. Two mechanisms are responsible for immunity. Firstly, proteins(globulins) are the vehicles of the defence funetion. These are calledantibodies and are the mediators of humoral immunity. Secondly, thereare cells (lymphocytes, plasma cells, phagocytes, macrophages) that canrender detrimental substances harmless. We call this cellular immunity.Humoral immunity There are numerous interactions between the two systems (humoraland cellular) [4]. There are numerous antigenic substances, includingvarious pathogens, that are able to produce an immune reaction. Fur­thermore, antigens have the ability to react specifically with an antibodyor a sensitized lymphocyte. Antibodies are present in all body fluids: inthe blood, the lymph, and in loose connective tissue [5]. These antibo­dies, which are formed primarily in the lymph nodes, have learned to re­act against very specific invaders. Antibodies are globulin molecules,which can be separated into five different fractions by means of a specialchemical process called immunoelectrophoresis. Immunoglobulin A(IgA) and immunoglobulin G (IgG) have substantial protective proper­ties against viruses, bacteria, and mutant cells of the body itself. Immu­noglobulin M (IgM) (for macro) reacts especially quickly. It representsthe shock troop of our defence system. Then comes immunoglobulin G(IgG) followed by IgA whose protective effect is less rapid but more sus­tained. IgE is especially important in the case of allergies. IgA occursabove all in mucous membranes and has the function of fending off theattackers on the spot - before they can enter the body fluid or the lymphsystem. IgA [6], produced by plasma cells, is provided with a secretoryportion of epithelial cells and mixed with the secretion of the mucosa. Itis found in saliva, tears, milk, and colostrum and in the wastes of the gas­trointestinal, urogenital, and respiratory tracts. These immunoglobulinsare not produced and present to the same degree in all people. One thingis certain: Iymphostasis (blockage of the lymph) can prevent the in:mu­noglobulins from reaching the sites where they are needed. Thus, in theprotein molecules there are defence functions [5] that we all possess, and 29
  • 30. in the lymph vessels and lymph nodes there is a special defence reactionthat results from the synthesis of specifically acting antibody globulins.Although they are all immunoglobulins, each is designed to put one par­ticular opponent out of action. Proteins are produced by the liver [7], which receives the buildingblocks of proteins, namely amino acids and peptides, from the intestinalwall via the bloodstream. Albumins are released by the liver directly intothe bloodstream, but globulins are stored in certain cellular systems(plasma cells, macrophages, lymphocytes, thymus gland, reticular cellsof the spleen, and in connective tissue). From there they can be dispatch­ed - independent of the variable protein supply in the diet - into thebloodstream to meet the immunological needs of the body. To a lesser extent, the kidneys, spleen and lymph system are also in­volved in the synthesis of proteins from amino acids received in the diet.It is therefore essential that protein be supplied at meals to satisfy thebodys needs. At the same time, however, a constant protein diet shouldbe discouraged on the grounds that if continued over extended periods,it may lead to hypoporopathy (lowered permeability of capillary mem­branes due to thickening).Cellular immunity The cellular defence of the body is mediated by lymphocytes [4],plasma cells, macrophages, and phagocytes. Lymphocytes are especiallynumerous in the lymph nodes, spleen, lymph nodules and tonsils. Within the lymph nodes a distinction is made between the outer, corticaland the inner, medullary zones. In the cortical zone we find predomi­nantly lymphocytes arranged in spherical follicles, which may also pop­ulate the paracortical zones situated between the follicles near the ve­nules. The meduJlus consists primarily of macrophages and plasma cellsaligned in filaments around the lymph sinus. Two types of lymphocytes are known: T lymphocytes and B lympho­cytes [8]. These cells originate neither in the spleen nor in the lymphnodes. They migrate into these organs during an early phase of devel­op�ent, but are found originally in the red bone marrow. T lymphocytesreceive their characteristic features from thymosin of,the thymus gland,which they pass on the way from the bone marrow to the lymphoid com­plex. B lymphocytes are given their characteristic traits by a gland which30
  • 31. is known in birds as the bursa of Fabricus, a lymphoid structure near thecloaca. This gland has not been found in man, and we therefore speak ofa bursa equivalent. T and B lymphocytes are morphologically indistinguishable [4] . Both,appear as small and large lymphocytes. The most important distinctionis the presence of immunoglobulins on the surface of B cells, which arenot detectable on T cells. On the surface of a B lymphocyte are identicalimmunoglobins of one and the same type, all having the same specificityfor one particular antigen. Whenever a cell of this type encounters itscorresponding antigen, an antigen-antibody reaction takes place on itssurface. The lymphocyte then differentiates and upon completing a se­ries of divisions becomes either a plasma cell or a small lymphocyteagain. The plasma cell then produces and secretes antibodies. Uponcoming into contact once again with its antigen, the lymphocyte recogni­ zes it with the help of its surface receptors and changes into a blast. Thisis the vehicle of the immunological memory and is known as the memorycell. T lymphocytes can kill directly and are responsible for cellular de­fence. They usually assist the B cells in recognizing antigens. The maturation stages of lymphocytes can be divided into three func­tional categories of the lymph system: 1. Stem cells are formed in the bone marrow.2. Cells mature and are transformed into T and B lymphocytes.3. In the lymphatic organs - spleen, lymph nodes, Peyer s patches, tonsils - B and T lymphocytes are found in various ratios. These are immunologically competent against all antigens. Still another cell is involved in the immunological response: the mac­rophage. Unlike lymphocytes it is unspecific in its action. The immuno­logical benefit of MLD resides in the fact that pathogenic substancespresent in the body fluids are transported rapidly by manual manipula­tion to the lymph nodes, where they are inactivated. Generally speaking[6], successful defence against infection by microorganisms depends onthe degree of resistance and the presence of immunity. Resistance is un­derstood to be the entire defence complex that the body can mobilizeagainst the antigens of a pathogen before the immunological response isinitiated. Resistance is not antigen-specific. It is determined by geneticand environmental factors (nutrition, exhaustion , disease). There is nodoubt that resistance is strengthened by regular MLD. 31
  • 32. We also know through observation that we influence immunologicalevents and that the treatment of mucous membranes with MLD yieldsgood results. This is because we maintain or even improve the habitat ofIgA antibodies. d) Effect on the smooth muscles of the blood vessels and lymph angions (anatomy and function) MLD has a tonic effect on the smooth muscles of the blood vessel [9]. One theory is that the tissue pressure on the small arteries is lowered due to the drainage effect of MLD in the connective tissue. These small ves­ sels only have sparsely developed musculature and are thus quite sensi­ tive to tissue pressure. If this pressure should drop, the amplitude of the capillary pulsation increases followed by an increase in the speed of capillary blood flow. This increase in the rate of flow is accompanied by increased metabolic changes and resorption around the capillary. The tissue is then emptied. The lymph vessels are constructed differently from the blood vessels (draw and compare the two). It was Aselli who in 1 622 first observed contractions of the lymph vessels in dogs. It was not until 300 years later, in 1 956 that spontaneous rhythmical contractions of the lymph vessels were described in man by Kinmonth and Taylor. If we liken the blood vessels to pipes that are made up of three layers (intima, media, and adventia), the lymph vessels can be said to resemble a small heart in construction. Accordingly, the lymph vessels are built upof individual valve segments, called Iymphangions by Mislin, which areto be interpreted as anatomical and functional units. Each of theselymphatic segments has a valve that opens in only one direction. Thisdetermines the direction of lymph flow and prevents backflow. The ring­shaped smooth muscles of the segments contract in response to variousstimuli and press the contents of the lymph vessels, the lymph, in the di­rection in which the valves open. The innervation of the lymph vessels has been investigated by manyresearchers. It has been concluded that stimulation of various nervesleads to contraction of the lymph vessels, either actively or reactively.Mechanoreceptors have also been found in the lymph vessel wall. It maytherefore be stated that the lymph volume in the peripheral lymph32
  • 33. vessels determines the pulsation rate and thus the transport rate of thelymph. Stimuli produced by:a) Movements of the skeletal muscles.b) Pulsation of the arteries.c) The pressure difference in the thorax created by breathing.d) Peristaltic movements of the intestine.e) Manual Lymph Drainage. Apart from this the lymph angion also has a possibility of self con­traction. It contracts between 3 and 7 times per minute (autonomous orautochthonous) . The pulsation rate of the lymph vessels fluctuates between 1 and 30pulses per minute, whereby a relation between intra vascular pressureand contraction rate has been established. It is important to note herethat contractility of the vessel walls is also dependent on the tonus of thewall. The chief influence on pulsation, however, comes from stretching. Asdescribed earlier this can come from inside, i.e. by filling, and/or bystretching the vessel from outside. Mis/in has proved experimentallythat an increased contraction is produced by stretching the lymph angionlengthwise and transversely. Moving the skin during Vodders speciallymph drainage technique creates this lengthwise and diagonal stret­ching of the lymph vessels and thus leads to an increased contraction. An increase of the Iymphangio-motoricity will however always resultin an acceleration of lymph flow. Now we would like to visualize that the fluids within the individualbody cavities are in constant motion. This occurs as circulation withinthe spaces and as diffusion, osmosis, filtration or active transport acrossthe borders of these cavities. Since every fluid cavity constitutes a continuous system, the fluidwithin them is freely mobile. Factors that tend to impair free circulationare the resistance caused by friction along the adjacent cells and the in­ternal friction associated with specific properties of the fluid, i.e. the vis­cosity of the fluid. The chief causes of circulation are the contraction andosmotic gradients and the differences in the density of the medium whichis dependent on the temperature gradients in the individual cavities.Most important are the mechanical, motor driving forces. When body compartments are constructed and arranged in such a waythat the mechanical forces can and do give rise to regular movements of 33
  • 34. fluid, we speak of a circulatory system. Typically, the fluid flows throughsharply delineated channels, tubes or vessels. When vessels contract ac­tively, as the lymph vessels do, they then play an important part in fluidtransport - in this case lymph drainage. A closer look at lymph drainage reveals that there are three types:1 . Extravascular lymph drainage involves lymph formation and extra­ vascular circulation. Lymph is formed from: blood plasma which finds its way into the interstitial spaces by filtration or diffusion, from various proteins which enter the interstitial spaces in the same man­ ner and/or by active transport (cytopemphis), from large-molecular fat molecules from the digestive tract, from non-migratory cells (see also lymph-obligatory load). The more protein there is in the tissue, the less water can flow out of the tissue via the venous blood capillaries, because protein retains the water. By transporting protein out of the interstitial spaces, the lymph system again permits more water to flow out through the blood capillaries.2 . Extramural lymph drainage, i.e. the external mechanical influences on the lymph vessel. This is based on the fact that specific external for­ ces, as described, stimulate the angio-motoricity.3 . Auxiliary, indirect lymph drainage, which is supported locally or re­ gionally by manual, direct lymph drainage. To cite Mislin in one of his lectures: "If manual lymph drainage did not yet exist, it would have to be invented as it is now performed". I think this says every­ thing about the effectiveness of MLD. Recently Mislin has again described how the unique manipulations ofMLD stimulate the lymphatic motor system: Physiologic vasomotorlymph drainage is based on the autonomic pulsations of the lymph an­gion or chain of lymph angions. MLD probably exerts a decisive influ­ence on this system of drainage. The process is made up of rhythmicallyrepeating dilations and contractions of a continuous series of metachro­nous-functioning lymph segments. This gives rise to a peristaltic wave ofcontraction. The lymph segments are synchronized in their dilation-con­traction frequency and peristaltically metachronized in the resulting pul­sation. Myogenic automation and control of vascular activity by meansof synergistic-functioning receptors in the vessel walls ensure coordi­nated lymph transport. The main physiologic stimuli are pressure andtemperature stimuli. Intravascular transversal, but also longitudinal,34
  • 35. stretching sti muli increase the "pulse rate" of the lymph sections .Smooth muscle cells, such as those in the vessel wal l , exhibit electricaland mechanical reactions after undergoing passive stretchi ng . To regu­late their stim ulation in accordance with the prevailing situation , thevessel wall muscles with autonom ic, i . e . pacemaking, characteristics re­quire a dosed stretch i ng. This is dependent on the degree to which thevessels are filled. For all these reasons MLD, which imparts (to a certainextent inadequate) tensile sti muli on the physiologic level , stim ulates va- .somotor lymph drainage . We achieve this with the special lymph drainage technique of Dr.Vodder. The total pumping capacity of the lymph vessels is provided bythe sum of the lymphatic segments. An i ncrease in i ntralymphatic pres­sure can also result in an increase in the lymph pulse rate . The rate oflymph flow i ncreases with an increased lymph-obligatory load . Thismeans that i ncreased lymph production , for example though M L D , au­tomatically accelerates lymph drai nage . The contraction rate of the lym­phatic segments is also dependent on temperature, and i ncreases withrising temperature . e) Drainage etTect [29] The term "drai nage" certainly did not originate in biology , but rather ,strictly speaking, from farm i ng and agriculture . Here it refers to themethod , first practiced in England, of converting marshy land to farm­land by the removal of excess water. Th roughout the M iddle Ages , how­ever, no mention is made of draining waterlogged soi l . Not until themiddle of the 18th century is land drai nage mentioned. Relatively late inthe 18th century reference is made to drainage systems, i n which subsur­face conduits are used to collect and dispose of water. True drain sy­stems employ two types of conduits; field drains and collection drains.Field drains are designed to remove the water directly from the soi l .Groups of field drains then discharge the water into a collection drain .The field drains are generally laid out in parallel fashion , with the systembeing cross-connected to some extent by lateral conduits. A further fea­ture of drainage was the dra i n pla n , i .e . the drainage system was laid outin accordance with the features of the area to be reclaimed. As a rule thedrainage area of a drainage conduit i ncreases substantially with thedepth at wh ich it is laid . Naturally , the actual conduit diameter depends 35
  • 36. on the volume of water to be removed . The drai nage or drain plan chan­ges, depending on the terrain and the stratification of the soil . The pre­flood features of the drai nage area i n particular determine the size of themain conduit. The i nitial lymph drainage system is laid out according to the same cri­teria that have been tested and used in agricul ture. The ini tial lymph ves­sels serve as field drains and the lymph vessels of various orders as collec­tion drains . Brunner designated lymph vessels of various caliber as lymph vesselsof 1st, 2nd or 3rd order [32]. When we speak of drainage in connection with ML D , we are referringto the removal of fluid from soft con nective tissue. Thus we transportwater and s ubstances from loose connective tissue via the lymph system .These substances are referred to as the lymph-obl igatory load. Some wa­ter is also removed via the blood vessel system . Si nce this effect is of crucial i mportance to all professional groupsusing M L D , it will be treated in detail in a later sectioll . 2. Connective tissue a) Structure and characteristics Connective tissue is partly comprised of bone and cartilage, the hardsupporting substance, partly of taut connective tissue, i ncluding tendonsand fascia, and partly of loose connective tissue rich in cel ls, e . g . the sub­cutis . When we mention connective tissue here in relation to M LD, wemean the loose con nective tissue, the binding tissue that joins the cel lstogether to form tissue groups . These tissue groups join to form organs ,a n d fi nally t h e organs form an organism . Loose connective tissue ismade up of several substances , i ncluding the ground substance , consi­sting of: proteins as the soluble precursors of collage n ; non-collagenousproteins for forming protein-polysaccharide complexes, mucopolysac­charides ; hyaluronic aci d ; hyal uroni dase; chondroitin sulphuric acid;the various cellular elements , such as fibroblasts , from which small andlarge reticular cells arise; small and large round cells ; h istiocytes ; restingmigratory cells ; chondrocytes ; lymphocytes ; plasma cel ls ; granulocytes;36
  • 37. mast cells and fat cells . The migratory cells of the connective tissue areable to detach themselves from the tissue matri x . They then become mo­bile and are especially capable of phagocytosis. Various fibres are also components of connective t issue: collagenous,elastic and reticular fibres . Further constituents incl ude blood capi l laries and initial lymph vesselsand the end fibres of the autonomic nervous system . The nerves , vesselsand parenchyma cells form a triad which is capable of i nitiating regula­tion processes in the connective tissue. These regulation processes con­cern the above mentioned functions and abilities of connective tissue.ML D , a massage form adapted to this type of tissue helps to normalizethe function and composition of connective tissue. This is achieved be­cause with the special MLD method , fluid and sol utes in the connectivetissue can be displaced extravasally i n any desired direction . The connective tissue can comprise up to 70% water, is moveable andvaries in its viscosity. To cite an example from chemistry, one could sayit has th ixotrophic properties . The fol lowing experiment i l l ustrates anexample of thixotrophic behaviour: Bentonite and water mixed i n the proper proportions yield a masswhich also has thixotrophic properties . I f t h is mass is shaken in a bottleit will become fl uid, but if allowed to stan d for a while after s ha k i ng, itwill become gelat inous . Thixotrophy is the mechanical transformationof a substance from a gel to a sol and back . We s hould add here that inevery cubic centimetre of connective tissue we have other structures pre­sent. If we apply appropriate distortion forces to the conn ective tissue interms of pressure and s k i n movement (eg. l ight vibrations or MLD) ,then we can free the connective tissue of substances affecting it or thatare causing disease. ML D has the fol lowing effects on the connective tis­sue : the connective tissue is purified with small molecular substancesand water being resorbed i nto the blood stream . By stimulati ng the Iym­phangio-motoricity, the large molecular substances (we i nclude here thewaste metabolites and the whole lymph-obligatory load and toxins) areremoved from the connective tissue. The "lymph-obligatory load" includes all substances i n the connectivetissue which because of their molecular size can only be transportedthrough the lymph system . We describe here protein, cell, water and fatloads and i nclude glass, mineral or coal dust as well as bacteria . 37
  • 38. b) Function Connective tissue is an organ and as such has many functions and ca­pabi lities. I t is the vehicle of the u nconscious and undifferentiated bodilyfunctions. I t regulates e nergy processes and primarily controls the phy­siochemical and bioelectrical situation . It thus regulg1es such vital func­tions as temperature, water, mi neral and energy balance, including gly­colysis and respiratio n . It forms the basis of the system of ge neral andu nspecific defence regulation and with its fibres represents a mechanicalbarrier for bacteria . Wendt [24] has show n that connective tissue also serves a s the physiolo­gic reservoir of the h uman body for all essential nutrients . Protei n , car­bohydrates and water are stored in the connective tissue as well as fatcells which conta i n fat not yet transformed i nto energy . Excess dietaryprotein is stored i n collagen and the amino group of the mucopolysac­charide molecule. Water is stored within the structure of this moleculein the con nective tissue. Carbohydrates are stored in two different wa­ter-i nsoluble polysaccharide molecules; partly in glycoge n , a pure poly­saccharide that is mai n ly found in the liver and muscle cells, and partlyin the amino sugars called m ucopolysaccharides, wh ich are found in con­nective tissue and the basement membra n e . The mucopolysaccharidesin the con nective tissue represent the main carbohydrate reservoir of thebody . The m ucopolysaccharides i n con nective tissue vary according tothe amount and type of food i ngested ; i ts sugar content is in any cascconsiderably larger than that of the glycogen reservoir in the liver andm uscles, which only lasts from one meal to the next . Glycogen synthesisis u nder the i n fl uence of i nsuli n ; mucopolysaccharide synthesis is not . Water occurs in two different forms in the body: as active , hydrodyna­mic, available water and as i nactive , stored water. The first form servesas a means of transport in the circulatory and lymph system as well as inconnective tissue . I t functions as a reaction partner and as a solvent inmetabolic processes of cells and tissues . The stored water, on the otherhand is bound by the fibrils of the mucopolysaccharide molecules andi nactivated . It determi nes the volume of the molecule, wh ich is not acompact but rather a diffuse , externally open molecule that extends overa large vol ume, its so-called doma i n . The vitam i n a n d m i neral content o f t h e stored n utrients also fulfills astorage function . The calcium reservoir is bone , which is also a type of38
  • 39. connective tissue . The calcium is stored in the form of calcium phos­phate and calcium carbonate molecules . Evolution has placed this cen­tral reservoir for all nutrients in the most convenient spot i n the bodyimaginable - in the connective tiss ue . In this way the connective tissuefulfills two funct ions . First, it is an hydroculture in which all cells of thebody are suspended and from which all are nourished. Second, it is theubiquitous reservoir for all the nutrients of the entire organism . In thisway , every body cell can withdraw any nutrient from the tissue fl uid i nwhich it i s bathed . I f a nutrient deficie ncy occurs , every cell can at anytime draw nutrients out of the omnipresent reservoir without any delaydue to long transport routes . Some people are of the opi n ion that connective tissue be viewed solelyas a passive transit stretch for the transport of substances from the capil­lary to the cell and back . Pischinger [8] however, calls the con nective tis­sue an orga n . This leads to the term cel l-milieu system , which means thatthe life quality of the cells is depe ndent upon their environment. Weconsider the latter view logica l . Evidence for this view is the presence ofnerve fibres in the soft connective tissue, the termi nal stretch of the auto­nomic nerves . The axons of these nerves are able to release transmittersubstances directly into the connective tissue , thereby exerting a regula­tory effect . A further characteristic of connective tissue is its ability to regenerate .Scars are formed from connective tissue. Connective tissue has yet another important function as a defence sy­stem against life-threatening invasions from foreign cells , e . g . bacteria .The connective tissue fibres represent a protective barrier that detainsinvading cells until the defence cells can do their work . Fatty tissue is atype of connective tissue , serving both as a reservoi r and as padding. Extracell ular tissue, pericapillary tissue, transit stretch , interstitiumand basic regulatory tissue are various names for one and the same thi ng:the connective tissue. The different names for this tissue reflect its mul­tiple functions . From this it fol lows that a good healthy con nective tissueis essential for health and beauty . An accum ulation of metabolic wasteproducts impairs the function of connective tissue . In m ilder cases thisleads to cosmetic blemishes , in serious cases to health disturbances . Thesame is true if disturbances occur in the water balance of con nective tis­sue or if its composition deviates from the norm . 39
  • 40. c) Connective tissue cells Con nective tissue conta i ns cells that not only produce collagen andelastic fibres but also the ubiquitous half-gel, half-fluid, binding masswhich is a part of the ground substance . I t is through this ground sub­stance that transport takes place : the transport of n utrie nts from theblood capillaries to the cell and transport of waste products from the cellto the capillaries . The connective tissue cel l has all of the enzymes neces­sary for the synthesis of collagen [10], elastin and polysaccharide proteinsand can quickly produce several ti mes its own weight in extracellularsubstance . The conn ective tissue cells can only be supplied with buildingblocks by a suitable diet consisting of n utrient-rich foods plus oxyge n .Parenchyma cells are surrounded b y ground substance . The ground sub­stance is therefore i nvolved in nourishing the parenchyma cells becauseits condition will affect the rate of diffusion. I n a sense it is the environ­ment for the cells. This e nvironment can be clean and healthy or polluted with metabolicwastes and unh ealthy. It is easy to i magi ne that the cells fare better in ahealthy milieu . M L D cleans and purifies the tissue by drai n i ng it of pol­l utan ts [30]. H yal uronic acid is a constituent of the ground substance . Hyaluaroni­dase is the enzyme that breaks down hyaluronic aci d . These two substan­ces occur in the body in equal amounts . This equilibrium ensures thatsynthesis and breakdown balance each other out . The addition of hyalu­ronidase would upset this equilibri u m . Hyaluronic acid also serves as ce­ment for the filaments of the initial lymph vessels [II]. The use of hyalu­ron i dase in the form of creams , salves , i njections , tablets or i nfiltrativeliquids dissolves this cement on the filaments and causes i nsufficiency ofthe i n itial lymph vessels . I n beauty care , the use of substances containi nghyaluronidase should t herefore be strongly discouraged. 3. Transport systems in the body a) Water balance The body consists of one-third solid substances and two-thirds of a li­quid similar to seawater, evidence that we originally evolved from ma­rine life .40
  • 41. When we take a closer look at the liquid, we find i t consists of 5%blood , 15% connective tissue fluid and 40-45% intracell ular flu i d . Thefluids are vital to us because substances can only be transported in a li­quid milieu. Health is often dependent on the circulation of substances(metabolism), and is therefore a matter of adequate transport. Thedrawing to be made shows the blood separated from the i n tracel l ularfluid by connective tissue. This is intentionally so represented , since allsubstances that are transported i n the blood must pass through the con­nective tissue to reach the cells . Waste products formed d uring combu­stion must also pass through the connective tissue in order to be removedby the blood. This is an important fact and it is crucial to the understan­ding of how MLD works . solid portion liquid portion Fig. 1 41
  • 42. b) Circulation The left side of the heart pumps oxygen-rich blood through arteries,wh ich branch i nto smaller arteries, which further branch into arteriolesand these i nto capil laries. The capillaries consist of an arterial and a ve­nous part . From the venous part of the capillary the blood flows into ve­n ules, from there into smal l , then large veins. Fi rst-order veins bring theblood to the right side of the heart , the starting poi nt of the pulmonarycirculation, i . e . arteries transport the oxygen-poor blood to the pulmo­nary alveoli (capillaries) , w here CO2 is released and O2 taken up . Theoxygen-rich blood is then conveyed to the left side of the heart by ve ins.From there it is again pum ped to the capillaries, where O2 is unloadedfrom the "transport vehicle" haemoglobi n , and CO2 is loaded. Strictly speaking, O2 and haemoglobin become oxyhaemoglobin andthis oxyhaemoglobin rel eases O2 i n the capillaries, wh ich then di ffusesinto the tissue. On the other hand, CO2 is transported as gas dissolved inthe aqueous portion of the blood . Some of the CO2 in the blood then re­acts chem ically with water as follows: CO2 + H20 produce H2C03 or carbonic acid which dissociates to Hand HC03. The receptors for the concentration of CO2 in blood are inthe carotid sinus and i nfluence the breathing centre - this only as anaside . Parallel to the venous syste m , we have stil l another vessel system ,the lymph system , so that one can say the arterial network is the supplysystem to the tissues and the venous and lymph networks the drai nagesystems. They have different tasks. The venous system, besides havingthe task of conducting the blood back to the heart , must also removesmall molecular substances from the connective tissue and transportthem . The lymph system is responsible for removing large molecularsubstances and water from tissue and transporting them. Small molecu­lar substances i nclude salts, sugars, water, and gases. They have a mole­cular weight of less than 200 comparable to the head of a p i n . Large -molecular substances i nclude protein molecules of various sizes. Theyhave a molecular weight of 70 ,000 to 1 30,000 comparable to a boulder.A red blood corpuscle could be compared to an entire mountai n . Thelymph system can even remove the entire mountain , the blood cor­puscle, from the tissue and transport it away . This explains the excellentresults obtained in the treatment of blood effusions with MLD. Theselarge molecular substances, which can only be removed from tissue via42
  • 43. the lymph system , are designated lymph-obl igatory loa d . I ncl uded areproteins, immobile cells, cell fragments, waste products, bacteria , viru­ses, inanimate substance , surplus water and large-molecular fats. c) Lymph system Lymph vessels can be viewed with x-rays by fil l i ng them with a con­trast-medium fl uid. Blue dye bound to protei n is i njected subcutane­ously . After a while a lateral incision is made in the skin between the in­jection site and the heart, and the vessels are exposed . Those vessels thatare dyed blue are lymph vessels. These are now filled with contrast me­dium and can be radiologically displayed. The lymph vessels then usu­ally look like strings of pearls. The constrictions are the valves, thepearls are the filled lymphatic segmentsf25 1 . d) Lymph nodes Lymph nodes are included in the lymph paths as fil tering stations [25] .As a rule, a lymph vessel does not leave a n organ o r a body region with­out undergoing filtering through a lymph node. Lym p h nodes are con­nected to the ci rculatory system . They are made up of a con nective tissuecapsule, trabecula , marginal and intermediary sin uses, medulla, hilumand efferent and afferent lymph vessels as well as reticular tissue. Bloodvessels enter the lymph nodes at the depression k nown as the h ilum .Lymph entering by numerous affere nt lymph vessels is concentrated i nthe lymph nodes . These vessels pierce t h e lymph node capsule from allsides . The lymph flows into the marginal sinus then into the cavities crea­ted by the trabecula (intermediary sin uses) . It washes round the lympho­cytes, plasma cells, and p hagocytes, ie . all the cells of the imm une sy­stem and leaves the node at the hilum via efferent lymph vessels. I tshould be poi nted out that both B lymphocytes and T lymphocytes arefound in the lymph nodes . A lymphocyte that has been sensitized by an encounter with antigen isable to divide . In this way a defence system with a specific action is builtup. Both the sensitized lymphocyte and i ts desce ndants are able to reactspecifical ly agai nst this antigen and counteract it. 43
  • 44. Efferent lymph vessels Capsule Trabecula _--j���;:::Marginal sinus �������or cortical sinus - dimensional cell meshIntermediary sinus of the lympho­ reticular tissue lymphocytes are constantly being manufactured. Afferent lymph vessels Fig. 2: Di agram of a lymph node Agglomerations of B lymphocytes in the lymph nodes are calledlymph follicles . A distinction is made between primary follicles in thenewborn and the secondary follicles i nto which they develop i n responseto challenge by the i nfectious outside world . I n completing their routethrough the body, the lymphocytes rema i n for some hours to some daysin the lymph nodes but never more than 24 hours in the blood . The ac­tual life of B lymphocytes is 3 to 8 days , that of T lymphocytes 100 to 150days . I n the recognition of antigens the concept of self and nonself figurespromi nently. The feature self is embodied in all of the bodys intact mo­lecules , while the same molecule type produced in another i ndividual isrecognized as foreign because the spatial arrangement of its atoms is dif­fere n t . I t is proteins that mediate the characteristic self or non-self fea­ture . Thus viruses and bacteria , w h ich are made up of protei n , are com­batted by our i m mune system as well as degenerate cells from our ownbody.44
  • 45. There are more than 600 lymph nodes in the body , about 1 60 i n theneck region alone [23] . Lymph nodes not only bind, attack and break­down antigens , but substances are also deposited there which the bodycan not get rid of, e . g . glass dust, coal dust, mineral d ust and dyes . Thelymph is concentrated, with 40% of its fl uid resorbed by blood capi l la­ries . The close resemblance of the reticular con nective tissue to the em­bryonic mesenchyma explains, among other thi ngs , why surgically re­moved lymph nodes are able to regenerate completely from even smallremaining capsule fragments . After total extirpation no regeneration ta­kes place; also after induced chronic i nfections no new lymph nodes de­velop. Tn the physiologic or accidental i nvolution (retrograde change) oflymphatic organs the lymphoreticular tissue is i ncreasi ngly replaced, be­ginning at the hilus , by fatty tissue and collagenous con nective tissue.The lymph vessel system involutes especially i n the m ucous membranes ,so that in old age it is absent in many areas . Whether regular lymph drainage preven ts or delays the i nvolution ofthe lymph system is left to the readers i magi nation. The fact is that proofis still lacking. After working 20 years with M L D , however , we have theim pression the M LD does i ndeed bring improved function of the lymphsystem . W e know that organs wh ich are in contin uous use degenerate less thanthose which are used less or not at all . M LD ensures that the lymph sy­stem is constantly exercised. The tables "Defence System 1-4" (pages 47-48) list the regional andsupraregional lymph nodes , their drai nage areas and drainage routes .Of course it is i mportant for a therapist to know why a lymph node isswol len in order to arrive at certain conclusions . The majority of the organisms immunological reactions occur in thelymph nodes. On could also designate the lymph nodes as filtering sta­tions which i nsure that only purified lymph reaches the blood. Other­wise our blood would become contaminated . I n general the lymph nodesare devoid of musculature . There are, however, lymph nodes in the i nte­stinal region which are provided with m uscles and are t herefore able tocontract . 45
  • 46. Summarizing, the functions of the lymph nodes are:a) biological filter,b) concentrating lym ph ,c) immunological function (replication of lymphocytes ) ,d ) storage (for substances that are not broken down and cannot be removed such as coal dust etc . ) . e ) Anatomy o f the large lymph vessels The largest lymph vessel in the h uman body is the thoracic duct . Itoriginates i n the cisterna chyli , a large lymph cistern in the navel region,and ascends through the diaphragm in front of the vertebral col um n . Atthe level of the sternoclavicular joint it arches to the left and empties intothe angul us venosus . It transports lymph from the legs , skin of the abdo­men and buttocks , from all the abdomi nal organs and i n testi nes exceptthe convex side and capsule of the liver (this lymph flows through thediaphragm to the mediastinal and sternal lymph nodes , then via the d uc­tus Iym phaticus dexter to the righ t venous arch) . It can therefore be saidthat all lymph origi nating below the navel is transported by the thoracicduct . It also transports the long thread-like fat molecules , wh ich it ab­sorbs from the digestive tract . The small fat molecules reach the liver di­rectly via the portal circulation . We divide the upper half of the bodyvertically into symmetric halves . The upper left side of the body ( leftbreast , left back , left arm , left half of t he head) delivers its lymph to theductus Iymphaticus sinister, which empties into the angulus venosus atthe same place as the thoracic duct or shortly before into the thoracicduct itsel f. The upper right side of the body ( right breast , right back ,right arm , right half of the head) empties its lymph in to the ductus Iym­phaticus dexter, wh ich discharges into the subclavian vein under theright clavicle . Exceptions are the heart and the lower left lobe of thelung, both of w hich deliver their lymph into the right lymphatic duct.One can best learn the course of lymph drai nage of the skin by referringto Vodders illustrations , wh ich are based upon Sappey s I ndia-ink expe­rime nts ( 1 874) .46
  • 47. Table I : Defence areas (after BrclUs: from TischendOlf, F. , Lymphatisches System .Neuere Erkenntnisse liber d i e funktionelle Struktur. Vol . 22 of the advanced educationsseries from "medizin und information". Demeter Verlag, Grlifelfing 1 980). l. Defence area: head region ( table adapted from Braus) Boundaries: chi n , lower jaw , ear , occipital Lymph node Location Root area DrainageSUBMENTAL Below the chin 2-3 Lower lip, gums, tip Deep cervical nodes of tongue , chin lymph nodes SUB- 5-8 nodes in the area Lips, external cheeks, ditto MANDI- of the submandibular med. lid segments, BULAR glands teeth, gums, tongue, floor of mouth , cheek, mucosa PRE- I n �ont ofcar at and Front part of auricle , dittoA U RI CULAR in the parotid gland nasal root, lateral 2-4 nodes parts of lids with con- nective tissue, parotis RETRO- Behind the auricle, Auricle, chiefly pos- dittoAURICULAR [-2 nodes terior surface, neigh- bouring scalp, middle ear with mastoid OCCIPITAL Above the insertion Skin of back and base ditto of the trapezius muscle of the head, 2-3 nodes pharyngeal tonsils (but not regularly) II. Defence area: neck Boundaries: chin , edge of lower jaw , occi pitus and j ugular fossa , clavicle , midd le of nape of neck . Lymph node Location Root area Drainage SUPERIOR I n the area of the Ear, parotid gland, Deep cervicalSUPERFICIAL sternocleidomastoid angle of the jaw, lymph nodes CERVICAL muscle near the front of the neck , nape angle of the jaw (to middl e ) , back of head , tonsils SUPERIOR Along the internal Isthmus of Fauces, Jugular AND jugular vein 20-30 tonsils trunk INFERIOR nodes, supraclavicular(SUPRACLA- fossa VICULAR) DEEP CERVICA L 47
  • 48. III. Defence area: Wall of the upper tru n k with extremities Boundaries: j ugular fossa, clavicle , middle of the nape of neck and approx . a horizontal l ine through the navel . Lymph node Location Root area DrainageS UPE RFICIA L Prefascial in the axilla Lower part of the nape, Deep axillary lymph AXILLARY i n fatty tissue grouped extremities, skin of nodes. Infra and around the large chest and back, supraclavicular vessels mammary glands lymph nodes PECTOR A L Next to Pectoralis Mammary glands, Deep axi lIary major muscle, in the especially lateral lymph nodes area of the third quadrants serratus digitation (exit site of the inter- costobrachial nerve)S UPE RFICIA L Prefascial at the Ulnar skin of the ditto CUBITAL basilic vein, above forearm the epicondylus DEEP Crease o f t h e elbow Bones, joints, muscles ditto CUBITAL and connective tissue of the forearm and hand I V. Defence area: lower half on the body Lymph node Location Root area DrainageSUPERFICIAL Prefascial in the Trunk wall below the Deep inguinal I N GUINAL groin navel line, buttocks, lymph nodes perineum, external genitalia, uterine fundus, Lig. teres uteri , lower extremities POPLITEAL Superficial and deep Skin and deep parts ditto in the popliteal space of the lower leg around popliteal vasaFor more detailed information about the lymph pathways see Vol . 2: Therapy, by IngridKurz M D . t) Summary of transport systems in the body Subs tances i n the body are transported rapidly over long distances viapipelines : blood vessels and lymph vessels. The blood is driven by themain pump, the heart; the lymph by auxiliary pumps , the musculature of48
  • 49. the lymph vessels , the pressure difference created i n the thorax bybreathing, the movement of the skeletal m uscles , peristaltic movementof the intestine, and pulsation of the arteries . The transport of substan­ces in connective tissue is accompl ished by diffusion . 4. Substance transport a) Molecular motion Every molecule is in motion , owi ng to the thermal energy it contains.This motion would cease at absolute zero (- 273 °C or 0 Kelvi n ) . For ex­ample , the wood molecules i n a table top vibrate i n place . Molecules ofa fluid or gas move in a straight path until they collide with other molecu­les of the same type . They then ricochet like billiard bal ls , collide aga i n ,and thereby change their positio n . This spontaneous movement of mole­cules give rise to diffusion, provided that a concentration gradient exists .I f this is not the case , the molecules will still move , but then the processis no longer diffusion , which is a transport mechanism . b ) Diffusion [14] The molecules of a lump of sugar dissolving i n the bottom of a coffeecup are also i n motion , colliding with and rebounding off each other,some entering the sugar-free part of the coffee, so that eventually theconcentration of sugar i n the coffee is greatest at the bottom and tapersoff towards the top. The process of this sugar migration is caJled diffu­sion . After 4-6 weeks the sugar would be uniformly distributed through­out the coffee . We t herefore see that diffusion strives towards a concen­tration equilibrium or one could also say , diffusion moves i n the direc­tion of lower concentration . Strictly speaking, this is only a generaliza­tion . Some of the molecules , t hrough coll ision, also move in the direc­tion of higher concentratio n . StatisticaJly, however, the majority of mo­l$!cules move in the direction of lower concentration as a result of ran­dom col l isions. Diffusion is also temperature-dependent, i . e . the colderthe milieu, the slower the diffusion; the warmer the milieu , the faster thediffusio n . Large molecules move slower than smaJl molecules . The rate 49
  • 50. of diffusion i ncreases as the square of the distance . Therefore diffus ionrequires short distances if it is to effectively exercise its transport func­tion . I f the diffusion distance exceeds 1nm ( nanometre) diffusion becomesquestionable as a means of transport , because, for exam ple , it would re­quire an hour to cover 1 . 3 m m . On the other hand it takes only one thirdof a second to travel . 0 1 n m , the diameter of a large cel l . c ) Substance transport i n the connective tissue A n oxygen molecule entering the body through the lungs is bound tohaemoglobin in the alveoli and transported by the blood stream . It is un­loaded i n a capilla ry . The oxygen concentration in capillaries is high ,since oxygen is unloaded there , whereas the oxygen concentration in thecell is low because cells burn O2, The m igration of O2 from the capillaryto the cell and of CO2 from the cell to the capillary proceeds according tothe principles of diffusion . Like gases transported in tissue , food and vi­tal substances for the cells are also subject to the laws of diffusion . Thesame appl ies for waste products of cellular combustio n , which are takenup by the capillaries and transported in the bloodstream to the excretoryorgans . d) Osmosis In order to fully understand the transport processes at the capi llary ,i . e . diffusion , filtration and resorbtion , we need to explain the term os­mosis . Osmosis is diffusion through a semipermeable membrane. If thismembrane separates two solutions of differing concentrations e .g. waterand saltwater , then the two solutions have different "water concentra­tions " . The side con taining salt has less water molecu les . The other sidestrives for a concentration equilibrium and water molecules diffusethrough the membrane towards the "salt" side . The i ncrease in pressureis called the osmotic pressure of the fl uid. Osmosis is the water-attrac­ting force of salt and sugar whereas oncosis is the ability of proteins totake up water .50
  • 51. 5. Effect of MLD on blood capillaries and connective tissue a) Structure and function of blood capillaries The blood capillaries show differences in their wal l structure , depend­ing on the organ in wh ich they are located . In other words, the capillariesare organ-specific in their constructio n . Th us there are regions in wh ichthe capillaries are more or less impermeable . There are also "fenestra­ted" capillaries or simple porous basement membrane tubes that areli ned on the inside with a layer of endothelial cells and coated on the out­side with a layer of perithelial cells with diameters of 5-10 f.J., (5/ 1000- 10/ 1 000 nm) . Blood capillaries are someti mes narrower than an erythro­cyte . which must therefore deform itself to be able to pass through . Thebasement membrane is made of i nterwoven collagen fibrils embedded i na n amorphous ground substance . The collagen fibrils are n o t very tightlyin terwove n ; they have gaps measuring 30 to 45 A - occasional ly up to100 A . The base ment membrane separates at places to enclose a peri­cyte (they are often noticeable i n the brain but i n contrast are totally ab­sent in skeletal muscle ) . Pericytes contain the same organelles as e ndo­thelial cells, i ncluding abundant pi nocytic vesicles. The healthy base­ment membrane is 300-800 A thick . One capillary is approximately 1mm long, and all capillaries laid end to end would measure 200,000 km ­more than half the distance from the earth to the moon . Osmosis takesplace through the capillary pores. An estimated 70,000 liters of waterdiffuse through the capillary wal ls every day . This amount of water ispossible only because we have an astronomical n umber of capillaries inour bodies. According to Wendt, capil lary basement membranes, and i nmore extreme cases t h e intima o f the arterioles as well , represent a reser­voir for excess dietary protei n , thickening as they accumulate surplusprote i n . This constitutes a barrier to osmosis and thus to cel l nourish­ment and the removal of waste products from the cells. A capillary combi nes two opposing characteristics. It must be leak­proof, so that blood can tlow through it and it m ust be permeable , so thatsubstances can diffuse through its pores . Water and n utrients reach tis­sue via the capil lary wall not only by osmosis, but also by filtration . A nestimated 70 liters o f water - 1000 times less than through diffusion - is 51
  • 52. fil tered daily through capillary walls. Blood pressure is the driving forcebehind filtration and the amount of filtrate is determi ned by the bloodpressure i n the capillary . At the same time, other forces are operative,which will be described later i n the text. Resorption is part of the capillary filtration mechanism . Its function isto resorb the filtered water back i nto the capillary . The force that powersresorption is con tained i n the blood proteins which collect water bym eans of a special type of suction pressure k nown as oncotic pressure orcoll oid osmotic pressure . The average protein content of the blood is ap­proximately 7 .4% These proteins are able to resorb the water filtered atnormal blood pressure, so that a fluid equi libri um (Starling equilibrium)is mai ntai ned i n the pericapillary spaces. Thus, a flow of l iquid throughthe capiIlary is brought about by filtration and resorbtion wh ich occursindependently of diffusion . Diffusion is a flow of liquid through the cap­illary wal l i n to the connective tissue, where it is reclaimed via the onco­tic pressure of the blood protei ns. b) The Starling Equilibrium Starling described in 1 897 the four forces wh ich were effective on thecapi llaries : blood pressure and oncotic suction of tissue proteins as filtra­tion forces; tissue pressure and oncotic suction of blood proteins as re­sorbtion forces . Under physiologic conditions a fluid equil ibrium pre­vai ls at the termi nal vessels. Th is means that the hydrostatic capillarypressure filters fluid i n to tissue, while the col loid osmotic pressure agai nresorbs the fluid. Starling himself d i d n o t express h i s hypothesis a s amathematical formula which was done much later. The usual formulasare :1 . F CaAa(Pa - P t - 11pl + 11,) =2 . R CyAy(Py - P, - 11pl + 11t ) =1. F Filtration = Ca permeability coefficient in the arterial capil lary loop = Aa surface area of the arterial capillary loop = Pa blood pressure in the arterial capillary loop = P, tissue pressure = 11pl colloid osmotic pressure i n the terminal vascular bed = 11, colloid osmotic pressure in the interstitium =52
  • 53. 2. R Resorption = Cv permeability coefficient in the venous capillary loop = Av surface area of the venous capillary loop = Pv blood pressure i n the venous capillary loop = This Starlings Law only has statistical sign ificance as it does n t takeinto account that blood capillaries in most regions of the body are per­meable to prote i n . Also proteins can generally only leave the tissues viathe lymph pathways . Thus , wherever there is protein permeatio n ,oedema must arise. However, a n oedema only occurs when lymph drain­age is disturbed (see oedema ) . The permeability of the capillaries forprotein is regionally differe n t , as wel l as protei n passage i n the venulesby means of cytopemphis or as a result of permeabil i ty of the venulewalls . A functional lymph drainage is therefore necessary to maintai nthe fluid equil ibrium . Dr. Vodders lymph drainage stim ulates lymphflow , because its special manipulations accelerate the contraction of thelymph segments . The subcutaneous lymph vessels are i nterli n ked i n anetwork . With the manual acceleration of the lymph flow there is an in­crease i n the lymph flow of the entire region . This is associated with asuction action, which eventually exerts an effect in the soft con nectivetissue . c ) Dehydrating effect of M LD via the blood capillaries and lymph vessels At first , only stimulation of lymph flow was ascribed to Dr. Vodder smethod of Manual Lymph Drai nage . I t was assumed that M L D drainedoedematous tissue only through the lymph vessels . Scientific experi­ments were carried out on rats [ ,5. 16] i n order to prove this . Lympho­static oedema was artificially ind uced and then treated with M L D . Theresults were striking. The oedema was al most e ntirely dra i ned from thetissue by the action of MLD. The control group , on the contrary, had se­vere oedema . The oedema was drained from the tissue even though thelymph vessels leading away from the tissue had been tied off. Thesefi ndings raised new questions . H ow and through what means could theoedema have been drained if not through the lymph vessels? Two possibil ities arose: that the water was removed from the tissuesvia the blood capillaries and/or, as we now know , that lymph was shifted 53
  • 54. via the valveless in itial lymph vessels that lie in the subpapil lary layer ofthe skin ( Kubik s lymphatic areas ) to functional lymph vessels. As far as tissue fl uid is concerned MLD has two effective directions.First , the appropriate massage pressure has the same effect as an elasticbandage or the hydrostatic pressure in hydrotherapy , i . e . a resorbtive ef­fect . It is not known how m uch of the increase in capil lary blood flowcaused by MLD ( Curri [ 46]) is represented by a simultaneous i ncrease i nresorptio n . T h e second, dehydrating effect o f M LD occurs via t h e valve­less i n itial lymph vessels as mentioned already . Besides water, it is possi­ble to take protein out of the tissues as part of the lymph-obl igatory loadby sti m ulating the lymphangio-motoricity . This is how we have a flush­i ng effect of M L D on the lymph-obligatory loa d . It is obvious that themassage pressure applied will have a decisive influence on this effect .MLD especially differs from classical massage in that less pressure isused. Salts can have the same water-binding effect as proteins in the con nec­tive tissue. Mucopolysaccharides should also not be forgotte n . Theselarge molecules can store water and prote i n . It is not certain whetherMLD also has an effect on these bound substances - water and prote i n ,a n d at best only surmised . 6. The significance o f optimal massage pressure I n M L D treatment the optimal massage pressure is the pressure thatach ieves the best possible results . Thus, it is the pressure that removesthe greatest possible amount of water as well as prote in from the tissue .A closer look , however, reveals that a given effect is accounted for notonly by the massage pressure , but also by the way in which the pressureis appl ied. In the original Dr. Vodder method specific receptors are stimulatedthat e nsure optimal tissue drainage [27] . Si nce the condition of the pa­tients tissues varies widely , both the pressure and technique must beadapted to the fi ndings. This optimal massage can only be learned underthe supervision of a lym ph drai nage teacher with many years of practicalexperience in treating patients. The range of MLD tech niques is verybroad and correct pressure can only be learned by repeated comparison54
  • 55. between the student and the teacher. A defi nite upper pressure limit ismarked by the occurrence of pai n . Whe never M LD causes pai n , youmay be assured that it is being applied i ncorrectly . A reddening of theskin should be avoided if possibl e . MLD is classified within the broadframework of classical massage and is one of the large-area, soft massagemethods with a special technique that bri ngs about a pumping action i nt h e tissue . 7. Inertial Mass In order to understand M L D , the term "inertial mass" must be ex­plai ned . Honey for example, is an inertial mass . If a coi n is dropped intohoney it takes a time to disappear into this i nertial mass . A broken-down car is an inertial mass . What can we do to move it? I tcan be pushed , i . e . energy i s applied t o this i nertial mass to move i t . Wecan do this in two ways : we can take a running start at the car though weknow the inertial mass will not move . We can however apply energy byleaning or pressing against the car, though this will take more time. Nowthe inertial mass begins to move . These examples show that apart fromenergy , time is also needed to move the i nertial mass . Connective tissue reacts like an i nertial mass . This explains the longtreatment ti mes allowed d uring M L D . Our experience has shown thatthe longer the treatment takes the greater the success of treatment withMLD will be . This example shows somethi ng else as wel l . The greaterthe inertial mass (more fl uid in the tissue ) , the slower the techniqueshave to be applied if the fl uid in the tissues is to be moved. 8. Steel and rubber elasticity To demonstrate steel and rubber elasticity , i magine a T bar with asteel spring on one side and a rubber band on the other. If successiveweights of equal size are added to the steel spring it will stretch according­ly by equal distances . I f they are then removed one by one, the springreturns in equal steps to its original size . Thus a steel spring stretches 55
  • 56. proportionately to i ts original size . This steel elastic behaviour is shownby collagen fibres . I n contrast the rubber ban d stretches a lot with the first weight, less sowith the second and even less with the third weight, even though theweights are equa l . Th us it stretches disproportionately with the weightapplied. If the weight is removed after a certai n time then the rubberband doesnt return to its original position because rubber undergoes achange . The phenomenon is that this rubber band gradually shrinks to its origi­nal position , a process called Hysteresis. This process is dependent onthe age of the rubber and the duration of the stress (stretch ing) . Elasticfibres also have this typical rubber elastic behaviour. This is of t he greatest importance to all those practising manual lymphdrainage . Oedematous tissue that has been drained of excess water usingMLD does not return to i ts original position . In a sense it has been de­formed . By usi ng external support bandages or elastic stockings, weenhance our treatment and e nsure success treati ng such tissues . Wethereby prevent fluid returning to t he tissues and promote the hystere­sis .56
  • 57. 9. The lymph systemTaken from:FOLlA ANGIOLOGICNVol. XXVlIII7I8/9/80St. Kubik: Drainage possibilities of the lymph territories AFig. 3: Schematic representation of lymph drainage of the skin. A) areas, B) lymphatic skinzones, C) drainage pathways of congested areas. l ) skin areas, 2) precollector, 3) sub­ -cutaneous collector, 4) lymphatic skin zone, 5) ski n , 6) superficial cutaneous rete, 7) deepcutaneous rete, 8) subcutis, 9) fascia, to) normal lymph territory, 1 1 ) lymphatic water­shed, 12) congested territory. a) Lymphatic watersheds [3 1 , 47] The superficial drainage system is divided i nto lymphatic areas andterritories, depending on the size of the drainage paths . The overlapping 57
  • 58. skin areas (valveless, initial lymph vessels in the subpapillary layer of theski n ) , whose diameter varies from about 1 . 5 cm on the hands and feet to3 4 cm on the rest of the sk i n , are drained by valved precollectors. The -valves of the precollectors protect the initial network from backward fill­ing. The overlapping of skin areas perm i ts drainage i n every direction .The precollectors of several skin areas usually join with a tru nk collectorof the subcutis. The skin areas of one collector form a type of striped skinzon e . The skin zones are con nected with each other by anastomoses inthe cutaneous lymph vessel network and above all , by many connectionswith neighbouring col lectors . Kubik calls the skin zones of all the collec­tors of a lymph vessel bundle , a territory . The borders of a terri tory areknown as lymphatic watersheds and there are no collectors to connectthe territories . If the collectors are imagined as a net , the net ends at awatershed . Another network begi ns on the other side of this watershedwhich drains in a different direction . Normally lymph does not flow overthe watershed because the resistance to flow in this direction is greaterthan the direction of flow of the territorial col lectors . These two drainage territories separated at the level of the collectorsare nevertheless interconnected . Si nce they anastomose with eachother, it is possible i n pathological cases to drain lymph from one terri­tory, over a watershed to another territory by means of ML D . This is viathe precollectors and valveless cutaneous vessels. The subcutaneouslayer of the skin is usually affected in oedema . This is why it is importantto in fl uence the superficial lymph vessels which dra i n the ski n and subcu­tis. These watersheds drawn by Kubik largely agree with those of Sappey.Si nce Sappey s drawi ngs helped Dr. Vodder to develop and specify hismanipulations for the manual drainage of the lymph territories, no im­provement was necessary when Kubik published his anatomic work onthe lymph system of h uman ski n . More evide nce of the acumen withwh ich Dr. Vodder developed man ual lymph drainage . b ) Mechanism of the initial lymph vessels The more protei n found in the tissues, the less water can flow out ofthe tissues via the blood capillaries because protein binds water. Thelymph system is then responsible for transporting water Ollt of the tissuetogether with prote i n so that water can again flow out via the blood capil-58
  • 59. laries [ 14]. The initia l lymph vessels begi n bl ind in the tissues like the fi n­gers of a glove. They are joined by filaments to the collagen fibres of theconnective tissue . Now if the connective tissue swells due to an i ncreasedinflux of water , the pressure rises. The collagen fibres are separatedfrom each other and pull the fi laments fixed to the endothelial cells withthem . Openi ngs appear i n the in itial lymph vesse·ls, through which waterand large molecular substances ca n enter the lumen of the vessel . Largecells such as erythrocytes can also enter the initial lymph vessel in thisway . As a result of the modified pressure relationships created by the fil­ling of the initial lymph vessel ( t he connective tissue pressure decreasesdue to eflux of water and the i n ternal pressure of the i ni tial lymph vessel i ncreases) , the endothelial cells function as flap valves and close . The i n­ itial lymph vessel is now full and sealed . The filaments ret urn to their ori­ ginal positions si nce the amount of water i n the connective tissue has de­ creased. A recent publication by Tischendorf(25] and a personal discussion de­ scribes the action of initial lymph vessels as fol lows: Some of the initial lymph vessel e ndothelial cells are arranged in sucha way that they appear folded or ove rlappi ng. They are anchored in thelattice fibres of the connective tissue and held open by connective tissuepressure . Also prese nt are adjace nt e ndothelial cells bound together byhyaluronic acid ceme n t . The protein molecules diffusing into the ini tiallymph vessel ope n these cemented joi n ts by pushing hyaluron idase i nfront o f them. Hyal uronidase liquifies ( depolymerizes) hyal uronic acidcement and the protein slips i nto the i ni tial lymph vesse l . The cement re­solidifies afterwards . This hyal uronic acid-hyaluron idase i nteraction oc­curs con tin uously in the con nective tissue . From this viewpoint diffusion regulates the migration d i rection ofprotein and the rest of the lymph-obl igatory loa d . A proximal emptyi ngof the lymph vessels, e . g . through M L D , would thus i ncrease the diffu­sion pressure in connective tissue by promoting vascular lymph flow andthus ultimately removing protei n and the remai n i ng lymph-obligatoryload from the initial lymph vessel [ 28] . This proximal lymph drainage oremptying of the initial lymph vessels would also have the effect of lowe­ring the pressure inside the ini tial lymph vessels. This means that theexisting difference between blood , i nterstitial and i ntra lymphatic pres­sures would increase . According to Bargmann, i n tercellular fi ltrationinto the ini tial lymph vessels follows im mediately . 59
  • 60. I n Fol ia angiologica 7/8/9/80, G. Hauck describes prelymphatic tissuespaces and channels (also Casley-Smith, 1976) , which are located in thecon nective tissue space and have the function of transporti ng proteinsfrom the bloodstream relatively q uickly to the initial lymph vessels . Heobserved that the elastic fibres of the connective t issue serve as guiderails for fluid transport . The rate of fluid transport is higher along theelastic fibres than by diffusion . The d iameter of these chan nels is smal lerthan that of the i nitial lymph vessels and they show a microscopically dis­cernible wal l structure. The begi n n i ng of wall formation is visible underl ight microscopy and evaluated as the site of a continuous transition i ntothe lymph vessel system . These results permit the interpretation of thelymph system as a converging drai nage system that is completely open inthe periphery . How does lymph get from the i n itial lymph vessel i nto the Iymphan­gion? A skeletal m uscle suddenly contracting compresses the fi lled initiallymph vessel . The lymph then flows in the direction of least resistance,i . e . towards the open valve of the first I ymphangion . I t is then com­pressed by the contracting smooth m uscle and thus pumped along fromangion to angion . The formation of lymph is thus dependent on the con­nective tissue fluid vol ume, and is only i nitiated if the blood capillariescan not com pletely remove water from the connective tissue, i .e . if thetissue pressure rises . In such cases however, the lymph system is capableof removing as m uch as 100 times more fluid than it normally does . Thegenerally accepted normal daily lymph volume is 2-3 li ters . Free waterand molecules that bind water cause a pressu re i ncrease in connectivetissue. The initial lymph vessels then open and lymph flows . All the substances that are not resorbed by the blood-vessel systemare collectively called the lymph-obligatory load because the lymphaticsystem is then the only route available for normal izing the connective tis­sue composition. For the sake of completen ess , it should be noted that lymph vesselwalls are not absolutely watertigh t . The oncotic pressure of closelyneighboring veins works through the wall and mai ntains "concentrated"lymph by resorbing water from the lymph vessels . Hyal uronidase is employed as a drug medium in medicine and as anagent for treating pan n iculosis i n cosmetics. It is sold in creams , tablets ,and ampules . As early as 1 967 [I I ] it was evident that the enzyme of hya-60
  • 61. l uronic acid causes the filaments of the endothelial cells i n the i nitia llymph vessels t o rupture . Hyaluronic acid i s the substance that cem e n tsthe fine filaments to the endothelial cells a n d to the collagen fibres . It isfool ish and destructive to use hyaluronidase. According to Foldi, theconnective tissue ground substance is altered through depolymerizationof the m ucopolysaccharides and the cemented join ts of the filaments (asdescribed above) are dissolved . The i n itial lymph vessels collapse as a re­sult of tissue pressure if the filaments are loosened from their anchorage .Lymph production is thus made impossible . c) Protein circulation and transport In this context , large molecular substances are mostly protein molecu­les . If there is too much protein in the blood [22] , e .g. after a protein-richmeal , the capillary endothelial and epithelial cells act as regulators toreestablish normal blood protein concentratio n . The endothelial cellshave three mechanisms for removing protein - i ncluding i m mune pro­teins and antigens - from the bloodstrea m .1. Si nce t h e highest protein concentration i s i n t h e blood, t here i s a con­ stant stream of protein to the i ntercellular spaces. The smaller pro­ teins (albumins) especially , seep through large pores in the capillaries and thus reach the connective tissue.2. The active transport of proteins through the endothelial cells by means of pinocytic vesicles which is known as cytopemphis . A large number of pi nocytic vesicles are found in e ndothelial cells . The transport mechan ism is as follows : The endothelial cell mem­ brane projects into the lumen of the blood vessel and tak es up a prot­ ein molecule which it then encloses i n a vesicl e . The vesicle carries t h e protein like a n elevator through the cel l , puts it out on the other side and releases the protein . Protei n is constantly bei ng transported from the blood to the tissue by t h is method of cyto­ pemph is . The transport of other s ubstances by an active process is known as pinocytosis .3. I n order for a protein equilibrium to occur i n the blood , t here must be a mechanism to accommodate the fluctuations i n protein concentra­ tion relative to diet . Accordi ng to Wendt [24], this mechan is m is lodged i n the ability of the endothelial cells to take up protein from 61
  • 62. the blood and during a lowered protein i ntak e , to return i t . Th is maintains a constant blood protei n leve l . I n t h e case o f endothel ial cell permeation v i a cytopemphis the molec­ular structure of the transi ting protein remains unchanged, whereasproteins entering the cell and permeat ing the endothelial cytoplasm usu­ally undergo molecular change . The flow of transe ndothelial proteinfrom the blood to the basement membrane is a physiologica l , active pro­cess of endothelial cells. They withdraw protein from the blood, trans­form it i nto insol uble mucopolysaccharides and deposit it on the base­ment membrane. D. L. Fry concluded from this (at the 1 2th Ciba Sym­posium in London) that the endothelial surface is extremely sensitive toevents occurring in the blood flowi ng by. This sensitivity can be seen asa mon itoring function of e ndothelial cells i n relation to cndogenous sub­stances with elevated blood levels as well as to foreign substances, e . g .antigens. The physiological protein flow from blood into tissue through the en­dothelial cells and basement membrane, proceeds in such a way thatprotein permeating into tissue from the blood interacts with the base­ment membrane while passing through i t . This protein permeation de­creases permeability of the vessel wall by thickening it. The basementmembrane is displaced from i nside towards the outside because endo­thelial cells withdraw protei n from the blood , transform it i nto i nsolublem ucopolysaccharides, and deposit it on the basement membrane. Theepithelial cells transform the protei n into soluble tissue protein on theouter wall of the basement membrane and release it i nto the tissue . I nthis way, t h e basement membrane slowly moves from t h e inside towardsthe outside, carrying the proteins deposited on it. Wendt calls this pro­cess glacial t ransport . Extremely efficient endothelial and epithelial cellsbreak down resorbed prote i ns completely. ]f the protcin is forcign , it istransformed into euprotein and poured back into the blood or trans­formed i nto m ucopolysacch aride and deposited on the basement mem­brane. Weaker endothelial and epithelial are often unable to breakdownand transform all of the protein . If there are antige n-anti body comple­xes, some of these are deposited u nbuffered on the basement mem­brane, which then causes i nflammation (capi llaritis) . We therefore have a physiological protein reservoir in conncctive tis­sue and a protei n reservoir in the basement mcmbrane - primarily in pa­thological situations. If the storage causes the basement membrane to62
  • 63. become thicker than 1 400 A , the condition is pathological and fi ltrationand diffusion are impaired. The bodys regulatory mechan isms are re­sponsible for adequate nourishment of the cells. This is accomplished byincreasing the blood pressure in order to reestablish normal fi ltrationand diffusion despite thickened basement membranes . Thus the perme­ability for protein depends on the degree of swelling of the basementmembrane. Contin uous resorption of excess protein fi nally overloads the base­ment-membrane protein reservoir. The proteins become congested i nthe blood . They are t h e n resorbed b y arterial endothelium a n d deposi­ted subendothelial as collagen on the intima of the arteries. Th is is thepathogenesis of arteriosclerosis and its associated risks. We would first of all like to distinguish between physiological andpathological protein and food storage [22] . 1 . After healthy people eat a well-balanced meal the blood levels of allthe nu trient molecules are initially elevated . Reduction of the elevatednutrient levels to normal is achieved th rough the h igh diffusion pressurescreated by the elevated nutrient blood levels, which drive the n utrientmolecules through the pores of the blood-capillary basement membraneinto the connective-tissue : protein in collage n and the amino groups ofmucopolysaccharides, gl ucose in the sugar part of m ucopolysaccharides,fat i n fat cel ls, and excess water in the domain of the m ucopolysaccha­ride molecules . All the different types of nutrients are thus stored in theconnective tissue , each in a storage molecule . The subcutaneous con nec­tive tissue of an overfed person may in this way become several centi­metres thick . The volumi nous connective tissue reservoir i n overweightpeople is not only crammed with fatty tissue , but with all the other n ut­rients too , their relative proportions depending on the nat ure of the dietthat has led to the overweight condition. As long as the capil lary basement membranes are healthy, their poresopen and the transport routes clear , all n utrients enter the connectivetissue for cell nourish ment or for storage . Th us the overfed person beco­mes overweight but remains healthy because an i ncrease in con nectivetissue storage molecules has no harmful consequences. 2. Nutrient storage , especially protei n storage , may become patholo­gical , from eating too much food rich i n animal protei n . In this case ,protein transport from blood to tissue is i ncreased, leading to impairedprote in transport through the basement membranes d ue to protein de- 63
  • 64. position on the basement membrane and its consequent thickening. Thisresults from o ncosis and from progressive obstruction of protein passagethrough the basement membrane via the sieve effect . (Sieve effectmeans that molecules cannot diffuse through the pores if a great numberof these molecules appear at the capil lary membrane at the same time .For example , if sand is shovelled i n to a sieve that is not in motion , thesand will remain i n the sieve even though t he grains are smaller than theholes in the sieve . ) According t o Foldi, all protei n molecules leave the bloodstream with­in 24-48 hours. They enter the connective tissue and are for the mostpart transported back to the blood via the lymph-vessel system, so thatone can appropriately speak of protein circulation . The average diame­ter of a blood-capillary pore is 80-90 A, occasionally 100 A [7 ] . Albuminhas a 70 A diameter; a single molecule can pass through the large poresi n to the tissue . Gammaglobulins are larger than 1 00 A . Albumin is atransport vehicl e ; i t transports water, metals, enzymes, vitamins, peni­cillins, insulin , hormones. Gammaglobulins have defence functions;amino acids are t he building blocks of proteins and therefore also ofcel ls. Betaglobul ins transport fat-like substances. All together there areover 1 00 differen t proteins in blood . Bennhold [ 18] describes a vehicularfu nction of plasma proteins, transporti ng the vital substances to the cellsand the metabolic wastes from the m . The manifold duties of proteinsshow that protei n circulation is no less important than any other circula­tion, and protein circulation takes place in the lymph vessels. Protein circulation therefore requires a well-functioning lymph vesselsystem , otherwise the con nective tissue becomes congested with thelymph-obligatory load . I f protei n remains i n connective tissue for toolong, its molecular structure changes and it is perceived by the body asforeign . Fatty meals place stress primarily on the lymph system . Large­molecular fats cannot reach the l iver via the portal vein circulation likesmall-molecular fats, but are transported i nto the bloodstream via thelymph vessels of the i n testine, the cisterna chyli and the t horacic duct .These m ust be i n good functional condition to transport away the "fatload" following the i ngestion of fatty food.64
  • 65. 1 0. Eq uilibrium and balance as a goal of massage a) Bathtub In order to again explain the problem "cosmetic or physiotherapeutictreatment with or without lymph drainage" again from another poin t ofview, we draw a bath tub, the contents of which represent connective tis­sue . The i n flow is filtration through the arterial syste m , the outflow re­sorption i nto the venous system . Every bathtub h as a n overflow drain toprevent flooding ( this is the lymph system ) if we forget to turn off thetaps. This should act as a safety valve. We h ave balanced conditionswhen the bathtub is full and i nflow equals outflow . Starling h as alreadydescribed this 100 years ago . If the drai n is blocked , that is resorption isnot functioning properly , the water level climbs up to the overflow ,wh ich m ust now remove the excess water. The same is valid for the situa­tion in wh ich fil tration outweighs resorptio n . The overflow drain of thebathtub, corresponding to the lymph vessel system , has a safety valvefunction . If for some reason this function is not fulfilled, oedema deve­lops. The lymph system is then no longer able to rel ieve the loose con­nective tissues of its "load " . This can be a "water load " , "fat load " , "cellload" or "protein load". The overflow drain in the bathtub fits into thisconcept : if the capacity of the overflow drain is exceeded or the drain isblocked for some reaso n , the bathtub will overflow . The disaster then ta­kes the form of oedema. In practice this means that it always depends on the type of tissuewhether and how we should combine circulation-stimulating methodswith MLD . I t also depends o n the drainage situation i n the tissu e . I f disturbancesof the venous and/or lymph system are present, the logical consequenceis that the return-flow system is impaired and congestion m ay develop i nthe connective tissue . I t would be a grave error to open the capillaries i nsuch a situation of impaired drainage b y stimulating circulation . Thiswould only serve to worsen the supply and drain age situation in the con­nective tissue, because i ncreased circulation not only brin gs n utrientsand oxygen into the tissue, which of course is very importan t , but alsomore water. Preventing this takes priority. Thus n o circulation stimula­tion in cases of impaired venous and lymph drain age! 65
  • 66. If our fi ngers feel soft , wea k , spongy , waterlogged tissue , we wouldtreat it with a few or no circulation-stim ulating measures (massage , fan­gotherapy , hot air, i rradiation , galvanization, hot or cold compresses,circulation masks) but rather with soothing and drai nage promotingmethods ( D r . Vodders M L D ) . We would otherwise upset the fluid equi­libri u m . I f w e feel firm, t a u t tissue , the entire range o f circulation-sti mulatingmethods may be applied , plus a short equalizing M L D . Filtration �-..- � al system �, ••� . ... . . . .. .. . . " . . . . .. . 0 •• . • ••� . . ... . . � " � .. .. .. •• . . ...... .. . � .. Lymph system Venous system Resorption Fig. 4 If the bathtub h as already overflowed , i . e . oedema h as already devel­oped, then under no circumstances should treatment be used that in­creases the load which m ust be transported by the lymph system . b ) Fluid equilibrium All circulation-promoting methods i ncrease fil tration into the tissue .In order to guarantee fluid equilibrium i n the connective tissue it is al­ways necessary, for safety reasons, to perform M L D . The intensity of66
  • 67. the drai nage depends on whether there are drainage problems in the tis­sue concerned . This is easy to determine by touch . Soft loose tissue ismore li kely to become oedematous and m ust be treated longer withMLD. Circulation should then be stimulated carefully and i n modera­tion . Firm , taut tissue can withstand more blood and requires lessM LD . l n the future MLD should be incorporated in cosmetic treatmentand physical therapy with these aspects i n mind. Sti m ul ate circulationfirst and conclude with MLD to maintai n the fl uid equilibri u m . c) Equilibrium in natural healing methods All natural heal ing methods strive to produce a state of equilibrium inthe organ ism . Consider the Chi nese art of healing, acupuncture . Anacupuncturist inserts needles i n specific places along energy paths ( meri­dians) in order to supply or remove energy and thus create balance i n theenergy paths. Yoga derives from the I ndian culture . It involves physical and spirit­ual trai ning as well as movements contai ning elements of tension and re­laxation with the goal of creating a balanced bei ng. Our therapists speakof equil ibrium of the autonomic nervous system which maintains humanhealth . There is yin and yang, acid-alkaline balance , and many other exam­ples in nature in which i n nate balanced interactions can be see n . If w e massage o r employ another circul ation-sti mu lating measure ,then drainage is the appropriate counterpart to guarantee fluid balancei n the tissues. 1 1 . Oedema forms I n 1 982, Winiwarter gave an excellent description of the developmentof lymphoedema: "At first the skin does not look different, only a little taut. Pressingwith a finger still causes a depression that remains, but the consistencyof the skin and the subcutaneous tissue is more elastic and soft thandoughy ( as i n the case of a simple oedema ) . When attempting to lift afold of the tegument, one notices that the skin is thicker, more resistan t , 67
  • 68. more tightly fixed to i ts foundation than is normal. Later, the consist­ency becomes progressively h arder and more firm or only part of the ex­tremity remains oedematous while the rest h ardens. Gradually, after 5-1 0 years, the circumference of the limb reaches absol utely monstrousproportions due to swelling. Usually the lower leg h as become a shape­less, uniformly thick cyl i nder similar to wide trousers gathered about theankle and suddenly n arrowing, or may have thick bulges and pend ulouslobes in fron t hanging down to the i nstep or on the side hanging down tothe ground l i ke the folds of a gown while the foot itself has preservednormal dimension . If however, the elephantiasis has spread downward,the foot appears as a massive, form less lump . . ." The classical division of l ymphoedema stems from Fdldi [18]. He sepa­rates oedema into three categories:1 . Lymphostatic oedema (due to mechanical insufficiency wh ich is brought on by organic or functional changes ) .2 . Lymphodynamic oedema (due t o a dynamic i nsufficiency ) .3 . Safety-valve i nsufficiency of lymph drai nage . Oedema develops when the transport capacity of the lymph system isnot sufficient to transport the lymph-obligatory load out of the tissue .The lymph-obl igatory load can vary according to the body region andthe disease . Thus we distinguish between water load , fat load, proteinload and cell load . The I ymph-time-volume is the amount of lymph that is transported i na given unit o f t i m e . I f t h e lymph-obligatory load i ncreases for some reason , oedema neednot necessarily develop . Rather, the lymph-time-volume increases as aresult of an i ncreased pulsation rate and amplitude of the lymph angions.Only i f the lymph-time-volume exceeds the transport capacity of thelymph-vessel system are conditions favorable for oedema. A mechanismthat prevents this i nitially is as fol lows: Monocytes migrate from theblood into an oedema-endangered area. In the connective tissue thesemonocytes transform into macrophages and consume the protein thereor break it into smaller pieces (proteolytic breakdown) . In this way theprotein load is dimi nished . Thus the oedema develops if the extralym­phatic cellular protei n regulation fails and the lymph-time-volume ex­ceeds the transport capacity for the lymph vessel system .68
  • 69. a) Lymphostatic oedema (protein-rich) Lymphostatic oedema is oedema resulting from mechanical inade­quacy of lymph drai nage . This mechanical i nsufficiency can be organicor functional in origi n . Organic changes h ave t o d o with con nective tissue and t h e prelympha­tic paths within it; they also concern i ni ti al lymph vessels with develop­mental disorders. Lymph paths may be obstructed by tumors, i nflamma­tion , or (in Africa) by parasites. They may be damaged by cuts, opera­tions, accidents, or x-rays. They can be constricted by tight clothing.There may be a paucity of lymph vessels. Functional changes may concern the initial lymph vessels, i . e . the fil a­ments could be ruptured . The changes may h ave to do with lymph ves­sels, i . e . if the valves do not close , the walls of the vessel are permeable ,the motoricity of the lymph angions are disturbed , or contractions of theskeletal muscle are absent (e.g. paralytic stroke or i nsufficient move­ment ) . The vessels may be cramped or paralysed. There may be a mani­fest haemodynamic i nsufficiency. The category of lymphostatic oedema h as been extended by one type ,first described by Price i n 1 970 [ 1 9] : endemic elephanti asis. It occurs i nEthiopia and results from walking around barefoot. Sil icate and alumin­ium are absorbed through the ski n , enter the lymphatic system and causedamage there . The result is oedema and elephantiasis. The fact that aterm has been coined for this disease , "lymphangioconosis" , de­monstrates the attempt to distinguish between the reaction of the lym­phatic system to absorbed, inanim ate particulate substances and typicallymphangitis. b) Lymphodynamic oedema (low-protein) I n lymphodynamic insufficiency there is a normal , functional lymphvessel apparatus. As a result of excess fluid however, the lymph vesselscan no longer remove the fluid from tissue . The result is a low-proteinlymphodynamic oedema. I t is only advantageous to apply m anual lymph drain age to oedemarich i n protei n . Low-protein oedema is not affected by M LD because the 69
  • 70. forces causi ng the oedema are m uch stronger than the influence of themassage . A k idney oedema is an example of a low-protein oedema, i . e . the k id­ney elimi nates protei n , which reduces the level of proteins in the blood.The oncotic pressure of blood proteins is thus dimi nished. The capillaryfilters as usual but resorbs less. The result is a low-proteinIymphodynamic oedema. The same holds t rue for h unger oedema. The oncotic pressure ofblood protei ns is also dimi nished , i n this case due to the absence ofdietary proteins. Thus the oncotic pressure of blood proteins sin ks and alow-protei n Iymphodynamic oedema resu lts. I t would be poi ntless toapply MLD to either of these oedema forms . It would not cause anydamage but would not h ave a positive effect either. Another type of low protein oedemas are those caused by heart insuf­ficiency - the so cal led heart oedem as . Foldi writes: The cardiac oe­dema is the resul t of a very complex process with a series of neural , hor­monal , circulatory and renal disturbances. The heart does not functionproperly. A mong other things, this leads to congestion in the venous sys­tem which extends to the capill aries. The pressure in both the venoussystem and the capillaries is elevated, which is synonymous with increas­ed fi l tration . I ncreased filtration with normal resorption can cause aIymphodynamic oedema when the lymph system can not compensate forthe excess fil tered fl uid. I n this case the lymph system cannot transport the ful l lymph-obliga­tory load . As a resul t of the h igh venous pressure the infl ux of lymphfrom the thoracic duct into the subclavian vein ( terminus) is also impair­ed. Congestion in the lymph system results (Iymphostatic component ) .I f w e were t o carry out MLD i n such cases, it would b e possible t o pumpa lot of fl uid via the venous and lymph systems i nto the right side of theheart . This would lead , among other things to a deterioration of the pa­tients condition. The consequence would be pulmonary oedema. Thus,never t reat cardiac oedema with M L D . Also enteropathic protein loss belongs t o this category. Proteins areexpelled with the stools. The i ntesti nal l ymph vessels become porousbecause the lymph is congested. Ulceration of the in testinal mucousmembrane leads to the escape of the lymph i nto the intesti nal lumen.Likewise , a congenital abnormality could be the cause .70
  • 71. c) Legs with varicose veins Varicose veins present a situation similar to " heart oedema" . A nelevated int(avascular pressure also exists i n the veins, distal venules,and capillari es because a col u m n of blood - usually i nterrupted by valves- causes an elevated hydrostatic pressure. We therefore again have i n ­creased filtration w i t h normal resorption . However the flow of Iymph­obligatory load i nto the venous arch is not disturbed . Some legs with varicose veins are also slender. The lymph systemfunctions efficiently and is capable of maintai ning the Starling equilib­riu m . However there are legs with varicose veins that are oedematous.Both the venous system and the lymph system are dysfunctional in thiscase. Some legs with varicose veins are slender i n the morning and thick i nthe evening. The lymph vessels are able t o remove excess fluid from tis­sue for a while, but after a certain poin t the amount of filtrate exceedsthe capacity of the lymph vessels and a low-protein lymphodynamic oe­dema results. This type of oedema, created by an elevated hydrostaticvenous pressure, cannot be cured with M LD either. We do , however,treat varicose veins i n order to stimulate the lymph vessels to performoptimally, i . e . do everything possible to stimulate the lymph system . d) Safety-valve insufficiency This is described by a sudden i ncrease in the lymph-obligatory loadand a total lymph congestion . If both disturbances occur at once then aquantitative change is seen in the oedema as well as a qualitative changeto the point of necrosis. 1 2. Cosmetic indications The first indication is the prevention of i mbalance i n t h e fluid equilib­rium . Drai nage is indicated after any circulation stim ulating measureand should therefore be part of every cosmetic treatment. 71
  • 72. General regeneration is a very important i ndication . I t is advisable togive 18 whole-body lymph drainage treatments at regular i ntervals ( forexplanation see "Con nective-tissue") . Acne i s a major i ndication. To ensure success, frequent and long treat­ments should be given at the beginning of a series of treatments. Thetreatment time should be at least 30 minutes per session. At this stage weshould warn you that a sligh t worsening of the acne might occur. Fordetails we refer you to our courses. All congestive conditions such as rosacea, facial erythrosis, telangiec­tasis, facial oedema , and h aematomas, the latter two also after face-lif­ting. Tear sacs, i f they involve proteinaceous oedema. All skin alterations resulting from protein accumulation in the con­nective tissue or chronic i nj ury : allergies, chronic eczema, burns, chro­nic i nflammation (take precautions) . Enhancement of general resistance. Scars become smaller, softer, and less visible. Favourable results have also been obtained i n the treatment of old andnew keloids. Panniculosis ("cellulite") is a very i mportant i ndication . Whethertreatment can be combi ned in this case with circulatory stimulationdepends on the drai nage situation . Soft, spongy, waterlogged tissue willnot tolerate circulatory stimulation of any kind. In maternal care , prevention of leg oedema by regular MLD and pre­vention of striae gavidarum (stretch marks) by timely skin care withM L D [201 . With m uch treatment, pre-existing stretch marks can improvewith M L D . A skin alteration caused by lymph blockage (Iymphostaticskin alterations) can lead to the disorder "cutis striata Iymphostatica".The h istological picture reveals damage to the elastic fibres. We maytherefore assume that prophylactic MLD will prevent the appearance ofthis disorder or restrict the alterations to mild forms . Thick legs, heavy legs , fatigued legs . Weight reduction cures combined with M L D will maintain" skin taut­ness. Mastodynia: this is described as the tension women feel in theirbreasts after ovulation , which can develop i n to pai n . This tension paincan also be traced back to lymph congestio n , among other things . Reg­ular M LD can provide rel ief here .72
  • 73. 1 3. Indications for physiotherapy The reader is referred to volume I I I of this book i n which Dr. ingridKurz discusses the pathology in connection with M L D . Zilch es] writeson the indications in the field of rheumatology, acute surgery and ortho­pedics. Parlilla [36] and Reiner e7 ] describe i ndications i n the area of generalmedici ne, Seeger [30 ] i n cancer prophylaxis and therapy. The reader isalso referred to the published papers of the scientifi c and practicalwork ing conference of the Society of D r . Vodders Man ual LymphDrainage, which is held every two years [38,39,40] . 1 4. Relative contraindications MLD can be used in cases of thyroid hyperactivity, but the area of thethyroid itself should be avoided . Do not treat profundus-terminus, butrather occi put-terminus. I n general, decrease the treatment periodssomewh at. MLD must feel pleasant to receive. Asth matic bronchial attacks are triggered by the vagus nerve . Si nceMLD also has a tonic effect on the vagus nerve, there is a danger thatMLD may precipitate an attack . For this reason begi n treatment of asth­matic patients in the attack-free period. The t reatment times should notbe too long. I t is better to carry out treatment twice i n one day . Omit themanipulation on the sternum. Lymph nodes which were once affected by tuberculosis are also con­traindicated. There is a danger that encapsulated bacil l i may again be ac­tivated by the massage . Oedema due to insufficiency of the right side of the heart may not betreated. There is a danger that the patients condition m ight worse n .Cardiac patients can, however, b e treated outside t h e oedema area, e . g .for headache rel ief. If a nevus represents a precancerous state, omit this area from MLDtreatment. Do not perform abdominal treatment during menstruation . Low blood pressure : I n such cases a whole-body treatmen t shouldnever be performed at the begi nning, as this would only depress the 73
  • 74. blood pressure even further. I t is best to begin with a small area and in­crease i t i n the course of time . I t h as been observed that overall bloodpressure even rises as a result . I n the above conditions M L D can be carried out , but only in combina­tion with special precautions.UNDER N O C IRCUMSTANCES SHOULD THE B EAUTICIANA TIEMPT TO TREAT A CLIENTS I LLNESS . Treatment should be termi nated whenever an effect is felt to be un­pleasant . The general rule applies : Dr. Vodders lymph drainage mustalways be experienced as pleasant . 1 5. Absolute contraindications The absolute contraindications are : All malignant diseases and all acute i n flammations. The reason is thesame in both cases: degenerate cells, bacteria and viruses are transpor­ted by the l ymph system . I f M L D were used, these could be forcedthrough the nodes w here they would normally be attacked and brokendown . Ultim ately they would find their way into the blood and spreadthrough the whole body . This would be a disaster. Because of the associated risk of embolism , recent thrombosis is alsocon traindicated . The so called " heart oedema" arising from i nsufficiency of the rightside of the heart is an absolute contraindication ( see lymphodynamic oe­dema) . 1 6. Treatment guidelines Excursus in the cosmetic field Let us examine what services beauticians perform for their customersand what effects they have . They massage, apply compresses - hot or col d , do vapozones, per­form peelings, carry out electrical sti mulation therapy , perform ion to-74
  • 75. pheresis, prepare circulation masks, apply thermal masks, and they irra­diate . All these measures stimu late the circulation . The maj ority of the treatments applied at a beauty i nstitute are relatedto blood circulation - from a physiological poi nt of view an extremelyone-sided treatment . Circulation , of course , is essential for supplyingnutrients and oxygen to the tissue, but water also enters the tissue .Blood flow opens the capil laries , and filteri ng is thus i ncreased. MLDwould counter this effect by transporti ng excess fl uid out of the tissues.A good approach is: first sti mulation of bloodflow and then lymph drai n­age . I n this way nutrients are offered and supplied quickly to the cells be­cause transit distance and thus diffusion time are short.Examples of treatment guidelines: Innammations Si nce inflammation, in addition to various types of oedema, is one ofthe main indications, we should discuss which forms of i nflam mation areindicated and wh ich contraindicated . I nflammation has five disti nguish ing features: redness, resul ting fromincreased circu latio n , swelling, wh ich results from enhanced permeabil ­ity o f t h e capill ary walls a n d i ncreased exudation , a s does t h e sensationof heat . The release of histamine from mast cells causes pain. Also , thereis functional impairment of the i nflamed area. First , however, inflammation shifts the state of the con nective tissuefrom a normal to an acidic milieu. As a result, the water layer around thebasement membrane becomes smaller and the pores become larger,thus i ncreasing prote in permeation . The lymph vessels react differently from the blood capillaries: in theinflamed centre they dilate so that the Iymphangion valves no longerclose . The lymph vessels proximal to the i nflammation , close spastically .Both processes have the same effect : lymph transport no longer takesplace. This react ion can be l ife-saving in cases where the i nflammation iscaused by toxic substances. These substances are bound to protei n andmust be transported through the lymph system . They would ultimatelylead to blood poisoning if this mechanism did not arrest the i nflamma­tion-producing substances until the phagocytosis system h as a chance toconsume them and break them dow n . Thus in the case of acute i nflam­mation caused by poisons, bacteria or viruses, MLD is con traindicated. 75
  • 76. Under the i nfluence of M LD the toxins could be pushed through thelymph nodes before bei ng elimi nated by our immune system . Theywould then fin d their way into the blood stream , causing blood poison­ing. I n cases where inflammation is not caused by toxins, bacteria or vi­ruses, M LD is the therapy of choice . Examples are cases due to i rritation(epicondylitis, tendosynovi tis, etc . ) or chronic inflammations, in whichthe inflammatory substances h ave been largely broken down. The thera­pist must therefore always consider whether M LD will spread or reducei nflammation on the basis of the above poi nts. I f the loose i ntestinal connective tissue is restored to a normal stateth rough M L D therapy, i . e . all pathogens h ave been transported out ofthe con nective tissue , the inflammatio n , which after all takes place in thecon nective tissue , is healed . In the normal ized connective tissue the ca­pillary filtrate is also restored to normal. The acidic milieu is neutralized . Acne Acne in its various forms constitutes a serious problem for the beauti­cian. The causes are so numerous that we can not simply say : first elimi­nate the causes and then treat the symptoms. That would requirespecialists from various medical fields. From our poin t of view acne is an accumulation of inflamed hair foll ic­les due to the conversion of sebum i nto fatty acid under the influence ofthe bacteria Corynum and Staphylococcus albus . The signs of inflamma­tion are redness , swelling, pai n and heat . Nearly all forms of acne mani­fest these symptoms. Excellent results are obtai ned by treating acne bymeans of M L D , provided that certain princi ples are observed . At firstthe acne m ust be treated with 30 m in ute therapy sessions every day : i nt h e first week a t least five times, the second week - a t least three times,the third week at least twice , etc. Before treatment a circulation maskshould be applied (do not clean each time ) . Do not wash the face withsoap or alcohol . Use a hydrophilic oil, if possible three times a day.Good digestion and proper eating habits, perhaps i nvolving a change i ndiet , should b e a goal . D r i n k m uch fluids - water or herbal tea. I f thesepri nciples are observed, it shouldnt be difficult to elimi nate the acne. I ti s then only a question of time. Acne m ust b e treated intensively andover a long period if favorable results are to be obtai ned . As mentionedearlier, sometimes acne appears worse after the first treatment.76
  • 77. If the acne to be treated is on the chest or back , we apply a hot com­pression of horsetail infusion for 10 m i nutes followed by M L D for 30 mi­nutes with outsta nding results. Cellulitis (panniculopathia-oedemato-fibrosclerotica) [46] / Adiposis Cellulitis is commo nly described as the appearance of an i ndented or"orange peel" ski n . One should always differentiate between adiposisand panniculopath ia-oedemato-fibrosclerotica ( the so called cel l ulitis) .I n women, there is often an accumulation of fat cells in the abdomen andouter sides of the thighs. This is a characteristic of the female body . Theview of this as beautiful or not has changed substantially. I f we look atthe paintings of Rubens for example , all of his female characters areshown with a massive "cellulitis" . Whether these are "adipose" figuresor if these women really suffered from the so called cellulitis cannot beseen in these representations. MLD can be used successfully with adipo­sis. However other methods m ust also be used, especially diet reduction .Vitami ns are very important as they are needed for metabolism of storedfat. N utrient intake must be reduced so that the body breaks down thefat depots and converts them to energy . Gymnastics can be done to tonethe affected tissues. A daily cleansing with hydrophillic oil h as provenhelpful and has a similar effect to the Kneipp hydrotherapy treatments. Whether MLD can be combined with circulatory stimulating methodsdepends on the feel of the tissues. If it feels soft and spongy, stimulationwould be i nappropriate because only more water would be pumped i ntoan already congested tissue , obviously suffering from drai n age pro­blems. If the tissue feels firm we are dealing with solid fat and circulatorystimulation followed by MLD can be used without a second thought .There need not b e any fear that t h e s k i n will become flabby after weight­loss because we specifically treat these areas. O n the contrary , the toneof the tissues i ncreases with M L D . Therefore, the s o called "cellulitis" o r medical ly speaking panniculo­pathia-oedemato-fibrosclerotica is, according to Curri, a pathologicalcondition of the fat tissue . With cellulitis, one shouldnt speak of fat ac­cumul ation, rather a structural disturbance of the fat tissue . The fat con­tent is normal in cellulitis. The local increase in volume can be tracedback to the formation of micro and macro nodules, small and l arge no­des . Besides this, fibres m ultiply and surround the fat cells. Please note 77
  • 78. that "cellul itis" is a disease of the fat tissue. This can occur in over­weight, normal or thin people . Also "cellul itis" is always related to ve­nous congestion and in many cases to lymph congestio n . I n t h e first stages o f cel lulitis there i s not yet a venous insufficiency butan increased capillary permeability. This isnt primarily caused by dam­age to the endotheli u m , rather by a disturbance of the pericapillary tis­sue, i . e . the connective tissue and its components. An oedema thusslowly develops i n the i nterstitium of the fat tissue which pushes apartthe fat cells . How does the fat tissue react now to this floodi ng? Some ofthe fat cells are destroyed so that fat mixes with the surrounding fl uid.Each fat cell is wrapped by reticular fibres which thicken and multiplyforming a type of capsule . These fibres transform in to collagen fibresand result in a sclerotic connective tissue during the course of the "cellu­litis" . This is nodule formation . I f more of these nodules combine andbecome surrounded by a thick con nective tissue capsule, they can be feltas nodes. This already represen ts the fi nal stage of the process. Curridistinguishes 4 stages of cel lulitis:1 . Floodi ng of the i nterstitium .2 . I ncreased puffi ness, i . e . the tissue becomes softer.3. Many small nodules and some large nodes ( macronodules) . An ex­ amination technique at this poi nt is to take a fold of skin fi rmly and hold it for 3-4 seconds. Upon release the patient experiences pai n .4. I n t h e fourth stage , t h e s o called orange peel s k i n develops , nodes can be felt and there is pai n . I t should b e noted that these four stages d o not develop evenly. I t isentirely possible that all stages occur at the same time . These circum­stances enable us to say that we can achieve very good results with "cel­lulitis" using man ual lymph drainage . According to Curri, the third andfourth stages of cel l ulitis are the fi nal stages and cannot be altered by anytherapy. However because all stages are found at the same time , it is al­ways correct to apply MLD . Also, this condition begi ns with an inunda­tion of the i nterstitium, i . e . it is always associated with an oedema . "Cel­l u litis" is never an inflammation . In many different ways the relationshipbetween the smallest vessels and the tissue are disrupted . Think of ve­nous congestion and also the effect of the birth control pil l . The effect offemale hormones on the ground substance of connective tissue is known .Oestrogen polymerizes the hyal uronic acid of the ground substance;progesterone or testosterone depolymerise and d isrupt the chain struc-78
  • 79. ture of hyaluronic aci d . During the menstrual cycle one can i magi ne atype of balance occurring which would be severely disturbed by the pil l .Curri [46] has shown i n experiments that M LD combined with a simul­taneous application of the cream Celuvase , bri ngs about a significant im­proveme n t . I t is a question of an effective treatment method absolutelyfree of side effects. Lipoedema Now a word about lipoedema. Here we h ave a symmetrical "saddle­l i ke" storage of fat especially on the legs but also on the arms. The feetand hands are normal (oedema free). There is a free transition betweenIipoedema and cellulitis. After a certain time cellulitis can also develop .Nodes are often visible and palpable i n lipoedema. Lipoedema is a verygood i ndication for MLD . Many patients suffering from lipoedema com­plain of pain especially during over exertion of the legs. B andaging ofthe legs should be a necessity but is often not possible due to the pain orinabi lity to wear the m . There i s a b i g difference between an adiposis, which is a general stor­age of fat and a localised lipoedema. Even on a minimal diet a lipoedemapatient would lose weight all over her/his body without a change in theIipoedema. The underpi nning scientific theories have shown us how totreat these patients: Dr. Vodders manual lymph drai n age ranks h ighlyas a basic treatment, possibly combined with a slimming diet. I n addition we combine compression bandages, thermal and electro­therapy in appropriate cases. Toothaches Under certain circumstances M L D can evoke pain in the teeth andjaws - namely, if the patient has a focus i n the dental region . Dead teethcan give rise to granulomas that are activated by MLD and become pain­ful . If a tooth is extracted and the jaw bone does not receive treatment ,residual ostitis may form which also reacts t o M L D . O n t h e other hand ,toothaches can also be elim inated using M L D , depending on theircause . 79
  • 80. Consideration of outside temperature The therapist m ust take even the outside temperature in to accountwhen treating a patient because it h as an effect on the skin capillaries. Body temperature is regulated by the blood. In order to cope with ex­treme fl uctuations i n outside temperature (winter -20° C , summer+ 30° C) and still maintain a constant temperature , the body has regula­tory mechanisms. I n a cold environment the blood circulates as much aspossible in the core of the body i n order to reduce heat loss to the out­side . When the outside temperature is high , the blood flows beneath theskin so that the capi llaries dilate and heat is dissipated to the outside .The capillary dilation h owever results in a large quantity of filtrate . Thismust be taken i n to consideration d uring therapy. On hot days , circula­tory-sti m ulating methods risk upsetting the Starling equilibrium morethan on cooler days . I n summer, therefore , emphasis should be placedon drainage and M LD with less circulatory stimulation and viceversa inwi nter. Iontophoresis If iontophoresis and M L D are combined to introduce active agentsinto the body , certain factors should be considered . I t is not very advan­tageous to perform M LD after iontopheresis, because the substances in­troduced into the tissues are removed again by drai nage . On the otherhand, galvanic current used in iontophoresis dilates the capillaries sothat the bloodflow is i ncreased, resulting i n more filtrate in the connec­tive tissue . M LD should therefore be carried out after iontophoresis, inorder to mai ntain the Starling equilibrium . So as not to impair the effectof iontophoresis, it should not be combined with MLD . For clients thatare oedematous or show a tendency to become so, iontophoresis wouldbe i nappropriate . Palpating will again reveal the state of the tissue . Soft,spongy connective tissue is in any case more oedema-prone than taut tis­sue . Iontophoresis on oedema-prone patients, as is often performed oncellulitis, always presents special problems.80
  • 81. Stress and Dr. Vodders manual lymph drainage Now I would like to say something about stress [33]. B asically stress isa useful , life-saving alarm reaction which enables us to react i m medi­ately with a flight or fight response . I n the "civil ised " world, stress has degenerated because w e are expo­sed to it day-in and day-out and cant escape from it. Because of this, se­vere injury and ill ness can occur as we cannot go through the so called"stress mechan ism " . In the moment of the stress situation the brain­waves abruptly change . This has a direct effect on the autonomic ner­vous system, via the hypothalamus. The sympathetic response puts thebody into an alarm state wh ich means: i ncreased blood pressure andpulse , release of the fl ight hormone adrenalin and the aggression hor­mone noradrenal i n . Fat and carbohydrate reserves are mobilised. Theresult is a decrease i n the skin resistance , caused by an i ncreased sweatsecretion through anxiety. The normal reaction to stress is the transitionto movement, i . e . fligh t , fight or another energy deployment such asshriek ing. This brings about a normal autonomic state . " Modern" stress, which has a continual weakening effect on us, has nooutlet because a series of restrictions imposed by civilization prevent thisinsti nctive impulse . The result is damage to the circulation , digestivetract and imm une syste m . Muscles, joi n ts and l ungs are damaged by de­posits and an accelerated agi ng process. At the same time, sensitivity toother stress factors is i ncreased. When the n utrients are unused , the fattyacids convert to cholesterol and are deposited on the vessel walls. Theresult is arteriosclerosis. Through a shift in the hormonal balance the au­tonomic system is disturbed , e . g. i ncreased strain on t he circulation andrisk of infarct ion. Hydrochloric acid prod uction i n the stomach is stim­ulated and the intesti nes tend to cramp. Even the structure of the coll a­gen in the connective tissue changes. Now si nce manual lymph drai nage has a sympath icolytic effect , it is i na position to break down the stress reaction and thus helps t o preventstress from making us i l l . This only concerns t h e effect of MLD on t h e nervous system . B ydrai ning t h e tissue a n d removing wastes from t h e loose con nective tis­sue , I bel ieve that hormones activated by the stress reaction are brokendown and taken away . A familiar quote of Vodder s was: " Lymph drai­nage norm alizes". 81
  • 82. When tal king of connective tissue one should also think of the connec­tive tissue in the vessel walls. Manual lymph drainage works here in thesame way. Looking at it this way, M LD is a rehabilitation method of thefirst degree . The most severe Iymhpoclasia occur in the lymph nodes and otherlymphatic organs, especially in acute strain as in stressful situations.Lymphoclasia in general refers to the breakdown of lymphocytes bym acrophages of the reticuloendothelial or histiocytic system.Clasma(cy)tosis describes the process of phagocytosis of aged and/ordamaged lymphocytes by clasmatocytes (h istiocytes) . I n the germi nalcentres of the lymph nodes and splee n , both lymphopoiesis (lymphocyteformation) and I ymphoclasia (lym phocyte breakdown) occur. Scars Scars are formed from connective tissue. Often the repair reaction isexcessive , resulting in the formation of keloids. These keloids are raisedabove the normal skin level. They con tai n more water and soluble col­lagen than normal scars. Both formation of scar tissue can be reduced oreven prevented by the regular application of MLD. Even the reddishdiscoloration of the scar disappears under the influence of M L D . Oe­dema forms along fresh laceration scars an� around the edge of large­surface burn scars. I t is important to drain this area. The objective of thetreatment is to render the scar stable and elastic, prevent shrinkage , re­vascularize the tissue , reduce discoloration , reduce the scar to the nor­mal skin level , elimi nate fibrosis and normal ize the tissue surroundingthe scar, i . e . i n most cases reduce oedema. Normally scar tissue is treat­ed with M L D like the skin lymph drai nage . Exceptions are made in thetreatment of secondary lymph oedema fol lowing cancer operations orafter 3rd degree burns. A n observation m ade i n Central America is worth noting: i n dark­skinned people scars are white, which, of course, is very conspicuous.When these scars are treated with M L D , a pigmentation process takespl ace [42 ] and the scar takes on the normal skin color.82
  • 83. B) Practical Section
  • 85. 1. Massage technique Dr. VoddersManual Lymph Drainage can be included in the classicallarge-surface massage methods. To some extent, the manual techniqueseven resemble the depletory manipulations of classical massage. A closeexamination, however, will reveal that MLD is considerably moredifficult as it involves manual techniques that are not used in any classi­cal form of massage. All massage techniques have one thing in common:by contacting the skin they stimulate specific receptors, resulting in aspecific reaction. The exact receptors that are stimulated and the effectthis has depends on the manner of skin contact. To achieve the effects ofDr. VoddersManual Lymph Drainage it is required that this method beapplied in its original form, as taught at the Dr. Vodder School in Walch­see. We distinguish between four different techniques: a) Stationary circles The fingers are placed flat on the skin and it is moved either in thesame place as "stationary circles" or in continuous spirals. The manipu­lations are used primarily for treating the neck, face and lymph nodes.The stationary circles are varied on the body and extremities by mak­ing circles hand-on-hand or with eight fingers placed next to each other.In the latter case the fingers turn together in the same direction to movethe skin in circles or alternating. The direction of pressure is determinedby the lymph drainage. The fingers lie flat, sometimes the whole hand.Each of these circles is performed with a smooth increase of pressureinto the tissue and a smooth decrease of pressure. b) Pump technique With this technique the palms are face downward. The thumb and fin­gers move together in the same direction, moving the skin in oval circles.This movement of thumb and fingers is controlled by the exaggeratedmovements of the wrist. The fingers are outstretched; the fingertipshave no function in this technique. The wrist moves like a hinge. The for­ward motion of the fingers is carried out with pressure ( as the wristdrops ) , the forward motion of the wrist is without pressure. 85
  • 86. c) Scoop technique In contrast to the pump technique the palm is facing upward. Vodderdescribes the movement as a "giving motion". The rotating wrist createsa corkscrew movement of the wrist-hand unit. The fingers areoutstretched and swing towards the body during the pressure phase.Pressure is on the inward part of the stroke with no pressure on the out­ward stroke. The pivot point is the metacarpal-carpal joint of the indexfinger. d) Rotary technique This technique is used on relatively flat areas of the body and consistsof various individual movements. The wrist moves up and down. As itmoves down it swings from the outside toward the inside. The wholepalm lies on the skin and turns it on an inward spiral. The thumb alsomakes circular movements in the direction of the lymph drainage of theskin. These motions are performed during the pressure phase. In thepressureless phase the wrist is raised and the four outstretched fingersmove on. As soon as the thumb has completed the circle, it begins to re­apply pressure. MLD consists of these four techniques, which may be combined dur­ing treatment. It can be seen from the description that Dr. YoddersMLD consists of a combination of round or oval, small or large, deep orshallow circular movements. The skin is moved rather than stroked. Forthe purpose of instruction, this principle is handled generously in basiccourses so that the direction of the movements becomes second natureto the student. Precise execution of the manual technique is then practiced in morcadvanced courses. e) Frequency ofmassage The length of treatment of a particular body part, the use of certainpressure and the speed of movements can be explained, but not taught.Thus, the theoretical lessons are only an aid to explain the effect ofMLDand prepare the ground for an understanding of the value and applica­tion ofMLD in physical therapy and health care. The dosage of MLD86
  • 87. however, must depend on the fingertip control and intuition of thetherapist and cannot be taught because in practice no two cases areidentical. Berta Bobath described in 1984 the Bobath concept: "However muchwe have learned and changed and continue to do both, it must be empha­sized that every basic concept has not changed. Each therapist works dif­ferently with her/his experiences and personality. This is positive andcreative. However, we all base our treatment on the same concept. Thisconcept is so far reaching and open that it enables us to expand our learn­ing and follow the continual developments in scientific research as wellas the changes in the symptoms of the disease". We want to fully applythis statement to Dr. Vodders manual lymph drainage. The descriptionofMLD must be seen and understood from this perspective. Since the effect ofMLD is largely derived from a mechanical displace­ment of fluids and the substances they carry, it is essential that the man­ual techniques developed by Vodder be precisely executed. Experienceshows that the more exact the technique is, the better the results are.The use of a particular pressure depends on the state of the tissue to betreated. One could say: the softer the tissue, the lighter the pressure. t) Environmental conditions for optimal therapy For an optimal treatment, certain environmental factors are takeninto account. Then the full effect can be felt on the nervous system with­out external disturbances, as well as the mechanical effect: 1. Conversation during therapy diverts attention and prevents autono­ mic changes. The patient should concentrate on the feelings in the skin. The attunement of the autonomic system will then be evoked via the skin senses. The same applies to interruptions in the treatment, e.g. if the tele­ phone rings, a new patient arrives, noise is made or the patients calm is disturbed in any other way.2. The patients table should be comfortable - not so soft that he or she sinks in, but under no circumstance too hard.3. The room should not be too hot or too cold but comfortably warm to promote relaxation. The indifference temperature for heat and cold receptors in the skin is 33°C (91SF). 87
  • 88. 4. The patient should not be dazzled by the glare of lights or radiation equipment.5. The skin contact zones should neither be too smooth, rough or moist. It is recommended that 2-3 drops of oil be used in treating the individual parts of the body. This will equalize the moisture of the skin. Under no circumstances should so much oil be used that one gli­ des over the skin, as is the case in classical massage. g) Basic principles The following are a number of basic principles that are characteristicofMLD.1. The proximal area is treated before the distal so that the proximal area is emptied to make room for fluid flowing in from the distal region.2. MLD prescribes a certain degree of pressure limited to 30-40 mml Hg.3. Each circular movement has a variance in pressure from about 20- 30-40 mm Hg, depending on the palpatory findings. The pressure is changed smoothly so that a pumping action is produced in the tissue.4. The direction of pressure depends on the efferent lymph vessels in the skin.5. The techniques and variations are repeated rhythmically, usually 5 to 7 times, either at the same location in "stationary circles" or in continuolls spirals. Less frequent repetition is pointless because the inertial mass of the tissue fluid needs some time before it responds.6. The pressure phase of a circle lasts longer than the relaxation phase.7. As a rule, no reddening of the skin should appear.8. MLD should not elicit pain.88
  • 89. Sequence of manipulationsI. Treatment of the neck (patient supine) All rotary motions of the hand or fingers are towards the little fingerside.1. Effleurage: Five fan-shaped strokes with the thumbs from the sternum to the armpits. The last stroke is along the clavicle (collar­ bone).2. Drainage of cervical lymph nodes: Stationary circles over the lymph nodes at the profundus, middle, and terminus with five circles at each point. 3 x.3. Occiput: Stationary circles beginning at the base of the skull, follow­ ing the cervical vertebrae and finishing in the terminus. 3 x.4. Stationary circles: three positions from the tip of the chin to the angle of the jaw then profundus, middle, and terminus. 3 x.5. Fork technique: Stationary circles in front (parotid) and behind the ears then profundus, middle, and terminus. 3 x.6. Shoulder: Stationary circles moving the shoulders: over the ball of the shoulder, two positions on the trapezius border then the termi­ nus. 3 x.7. Stationary circles starting again at the ball of the shoulder, then the acromium above the clavicle and then the terminus. 3 x.8. Stationary circles on the profundus, middle and terminus. 1 x.9. Final effleurage. 1 x. 89
  • 90. -..0o TEMPORALIS ...- _____ �- .....- "" GLABELLA PROTUBERANTIA -+ -PAROTIS OCCIPUT -- .... .... ....PROFUNDUS VERTEBRA PROMINENS-�.� / - I ,TERMINUS .... ......., �1t...� FOSSA JUGULARIS Copyright 1960 by ]Jr. Vodder, CopenJuzgen-. • Fig. 5: Trealment points.
  • 91. Arm and Breast)1 :� "..( -, I, 1. Ductus thoracicus 2. Ln. supraclavicularis 3. Truncus subclavius 4. Lnn. apicales (infraclaviculares) 5. Ln. interpectoralis 6. Ln. thoracoacromialis 7. Lnn. axillares centrales 8. Lnn. axillares laterales 9. A. brachiales; v. brachialis 10. Radial bundle along the V. cephalica I I. Ulnar bundle along the V. basilica 12. Lnn. cubitales profundi 13. Ln. cubitales sllperficialis 14. Lnn. pectorales 15. Lnn. sllbscapulares 16. Lnn.parasternales Fig. 8 95
  • 92. Fig. 996
  • 93. IV. Treatment ofthe legs 1. Long effleurage. 2. Pump technique alternating on the anterior side of the thigh. 3 x. 3. Pump - push along on the medial, anterior, and lateral side of the thigh. 3 x each. On the medial side push with 4 fingers and on the an­ terior and lateral side push with the thumb. 4. Treat inguinal lymph nodes with stationary circles using 8 fingers, flat and on a diagonal upwards. 3 x. Pressure is towards the finger­ tips (direction of drainage towards the inguinal lymph nodes) with circles toward the head. Then 3 continuous circles down to the knee with pressure on the upward part of the stroke. S. Treatment of the knee. a) Pump - push along on the "cauliflower". 3 x. b) Scoop technique upward in the hollow of the knee with 8 fingers flat. 3 x. c) Patella (knee cap): leave the fingers in the hollow and now make thumb circles on each side of the patella. 3 x. d) Pump technique with one hand over the knee. 3 x. e) Treat the Pes anserinus with alternating thumb circles. 3 x. 6. Lower leg with the knee flexed. a) Alternate between pump technique with one hand over the shin and scoop with the other hand over the calf. 3 x. b) Alternating scoop technique with the thumbs running parallel to the shin bone. 3 x. 7. Extend leg again. Parallel, 4-finger spirals on each side of the Achil­ les tendon. 3 x. 8. Ankle with alternating thumb circles. 3 x. 9. Dorsum of the foot with thumb circles alternating. 3 x.10. Parallel thumb circles (oedema technique) on lymph sea. 3 x.11. Pressing within the transverse arch. 3 x.12. Final effleurage. 97
  • 94. Front (ventral) of leg Back (dorsum) of leg ,I Fig. to98
  • 95. Fig. II 99
  • 96. v. Treatment ofthe nape ofthe neck (patient prone) 1. Effleurage with rotary technique from the middle of the thoracic vertebrae to the cervical vertebrae. 3 x. 2. Stationary circles over the profundus, middle and terminus. 3 x. 3. Stationary circles below the occiput then middle and terminus. 3 x. 4. Standing behind the patients head: stationary circles along the nuchal line from the middle of the head to the ears. Treat the entire back of the head in this manner. Each line 3 x. 5. Stationary circles on the side of the head to the occiput then on to the terminus. 1 x. 6. Grasp the occiput at the nuchal line, stretch the neck and vibrate. 3 x. 7. Pump technique over the shoulders until the thumbs are in the ter­ mini. 3 x. 8. Standing to the left of the neck: "Rabbit" technique ie. pump-push over the neck. 3 x. 9. Rotary technique over both shoulders, parallel 3 x. and alternating 3 x. Work over the shoulder muscles towards the terminus.10. With 8 fingers in one line, stationary circles on either side of the spine with pressure towards the vertebrae. 3 x.11. Vibration and final effleurage.100
  • 97. VI. Treatment ofthe back 1. Effleurage with parallel rotary technique: 3 x. from the shoulder blades upward. S x. from the midback upward. 7 x. from the lumbar region upward. 2. Alternating rotary technique over the right shoulder blade and right side of the back. Always start from the spine in a lateral direction in 3 rows down the spine, alternating to the count of six, then 3 rows back up the spine. 3 x. 3. Intercostal spaces with flat fingers using small oval stationary circl­ es. Cover the whole right ribcage 3 x. 4. Seven technique: beginning with the hand closest to the feet, alter­ nating rotary technique from the spine to the side (count to four) then pump - push without the thumbs along the side to the axilla (count to "se-ven"). 3 x. S. Large stationary circles in three places on the side, working towards the axilla. 3 x. 6. Stationary circles with both hands on the upper arm, two positions on the deltoid (pulling towards you) and one position pushing into the terminus and axilla. 3 x. 7. Change to the other side of the patient and treat the border of the right trapezius using the "cauliflower" technique. 3 x. 8. Repeat steps 2-7 on the patients left side. 9. Rotary technique on the extensors of the back: parallel, alternating, and in a number of different rhythmical variations.10. Triangle between the shoulder blades with rotary technique empha­ sising thumbs, first parallel 3 x. then alternating 3 x. With 8 fingers make very flat circles, pressure and direction to the right on the right side 3 x. and to the left on the left side 3 x.11. Edges of the shoulder blade with stationary circles (pads of the fin­ gers) directly over the edges. Pressure always toward the axilla.12. With 8 fingers in one line, stationary circles on either side of the spine with pressure towards the vertebrae. 3 x.13. Vibration and final effleurage. 101
  • 98. Fig. 12: Schematic representation of lymph drainage of the trunk wall (skin of back foldedout). - 1) Front vertical water shed, 2) rear vertical water shed, 3) transversal water shed,4) drainage area of the lateral upper arm fascicle, 5) front trunk wall, 6) side trunk wall,7) rear trunk wall, 8) interaxillary collaterals, 9) axilloinguinal collaterals, 10) amputationsite of shoulder.102
  • 99. Fig. 13 103
  • 100. VII. Treatment ofthe buttocks 1. Effleurage with rotary technique, parallel from the sacrum along the lumbar vertebrae. 3 x. 2. Rotary technique parallel, fanning out to the sides (count to seven). The last two motions are circles with flat fingers, no thumbs. 3 x. 3. Rotary technique alternating from the lumbar vertebrae over the right hip and gluteals (buttocks). 3 x. 4. Stationary circles hand on hand, down and up the iliac crest. Pres­ sure towards the fingertips and circles toward the head. 3 x. 5. Stationary circles below the iliac crest on 3 imaginary semi-circles over the gluteals. Fingers are placed in the direction of lymph flow, pressure towards the fingertips (inguinal lymph nodes) and circles towards the feet. 3 x. each semicircle. 6. With 8 fingers in one line, stationary circles on the right side of the lumbar spine and sacrum with pressure towards the vertebrae. 3 x. 7. Stationary circles in 3 places over the quadratus lumborum muscle between the twelfth rib and iliac crest. Pressure inward towards the spine. 3 x. 8. Repeat steps 3-7 on the left side. 9. Sacral triangle with rotary technique emphasising the thumbs, pa­ rallel 3 x. then alternating 3 x. Then with 8 fingers flat, as in the shoulder triangle.10. Vibration and final effleurage.104
  • 101. 107
  • 102. , ! Fig. 16108
  • 103. IX. Treatment ofthe abdomen1. Parallel rotary technique ( effleurage ) from the pubic bone to below the sternum 3 x then stroke over the solar plexus with the flat of the hand 3 x.2. Stroke over descending colon alternating hands, several times.3. Stroke over descending, ascending then transverse colon using both hands, i. e. in a triangular pattern, several times.4. Treatment of colon: with 4 fingers of one hand on top of 4 fingers of the other, make stationary circles over the descending, ascending, and transverse colon keeping the fingers parallel to the colon. 3 x. Press in the direction of intestinal flow.5. Seven technique: 4 fingers on 4, making progressive circles over the descending colon. Treat the ascending colon with alternating rotary technique, emphasizing thumbs and moving towards the hepatic flexure. Then use alternating rotary technique over the transverse colon. Count to "se-ven" over each part. 3 x.6. Weight reduction technique: alternating rotary technique, transver­ sely and if necessary longitudinally over the abdomen, several times.7. Panniculosis technique: small, light skin technique with the thumb twisting the skin against the index finger. Drain from the watershed to the inguinal lymph nodes, paying attention to the direction of drainage in the skin. Repeat several times.8. Treatment of deep abdominal lymph nodes: deep stationary circles placing 8 fingers above the pubic bone, at the side of the rectus abdo­ minus. Slow movements while looking into the patients eyes and pressure towards the cisterna chyli. 3 x on each side.9. Final effleurage with breathing. During inspiration, 3 flat rotary mo­ tions from the pubic bone to the sternum. During expiration, parallel stroking with the thumbs along the costal arches then with the fingers along the iliac crests and inguinal ligaments to the pubic bone. 3 x. 109
  • 104. the body lymph node groups in Main lymph trunks and 4110
  • 105. X. Therapeutic manipulations - special techniques For treating various diseases, skin or tissue changes, we use what areknown as therapeutic manipulations. These are the same as the techniques described in the practical part ofthis book. They possess the typical criteria of all manipulations used inlymph drainage: circular movement of the skin with a variation in pres­sure which is adapted to the symptoms and exerted in the direction oflymph flow. In addition, they are combined with various movement andbreathing exercises as well as bandaging if necessary. The duration oftreatment is adapted to the symptoms. Since there are so many indications for MLD and each indication oc­curs in countless variations, it is impossible to describe therapeuticmanipulations. They vary from one patient to the next. Training in ad­vanced courses enables the participant to treat any condition for whichMLD is indicated. Generally speaking, any part of the body can be ade­quately treated with the therapeutic manipulations using typical MLDtechniques [27].Fig. l7: 1. V. jugularis interna (sin.), 2. V. subclavia (sin.), 3. Ductus thoracicus, 4. Lnn.parotidei, 5. Lnn. subillandibulares, 6. Lnn. cOlllitantes n. accessorii, 7. Lnn. jugularis in­terni with Tr. jugularis (sin.), 8. Lnn. supraclavicularis with Tr. supraclavicularis (sin.), 9.Lnn. axillares with Tr. subclavius (sin.), LO. Lnn. intercostales with Tr. intercostalis (sin.),l 1. Lnn. parasternales with Tr. parasternalis (sin.), 1.2. Lnn. Illediastinales anteriores withTr. mediastinalis ant. (sin.), l3. Lnn. tracheobronchiales with Tr. tracheobronchialis(sin.), l4. Cisterna chyli, l 5 a. Truncus lumbalis sinister, 15 b. Truncus lumbalis dexter, 16.Lnn. mesenterici, 17. Lnn. lumbales, l8. Lnn. iliaci, 19. Lnn. iliaci, 20. Lnn. iliaci, 2 1.Lnn. inguinales. 111
  • 106. 2. Vodder on the technique of manual lymph drainage [I aJ "Working on the lymphatic system in such a way that good thera­peutic results are obtained is no easy matter. After all, the lymph vesselsare as thin as silk threads and lymph capillaries* are even finer and moredelicate. The classical massage techniques have no draining effect. If wemassage with hard, stiff movements, we are pressing the blood out ofone tissue and into another. The regenerating fluids do not find theirown way into the tissue. Sometimes all we achieve is a painful pinchingof the capillaries with resulting haematomas. Therefore, we must createa whole new technique. In order to achieve a movement of water, we have developed a specialpumping technique. It is as if a pump draws the fluid and transports itfurther. In our manual techniques, the hand rotates spirally into and outof the tissue. The lymph-draining action is in the hand and no equipmentcan ever replace an experienced hand. When these refined movementsare executed with the consciousness in the fingertips (soft as cats paws),we produce a calm, relaxed state that promotes lymph flow. Fresh oxy­gen and active substances penetrate through the interstitial tissue tonourish and regenerate the cells. The circular and spiral drainage manip­ulations are life-giving movements, as are all spiral oscillations in nature.The hand turning in and out of the tissue with rising and falling pressure(crescendo - decrescendo) is similar to the action of the heart with its sy­stole and diastole. It is well known that the rhythm of the heart is eight­tenths of a second, during which the heart rests for four-tenths of a se­cond. Thus, the heart rests just as long as it works and in this way cannormally operate for a full century without fatigue. We know masseuseswho have mastered our method of lymph drainage to such a degree ofperfection that they can perform the techniques without fatigue or exer-tion, delighting in tension and relaxation, building stamina during work,renewing energy during the pause. If you work harmoniously you willreally feel the flow of natural energy forces; you might call them cosmicforces. The purpose of lymph drainage is to transport used tissue fluid fromthe head and various regions of the body to the neck so tbat new, fresh* The term "lymph capillary" has now been replaced by "initial lymph vessel"-ed.112
  • 107. lymph can flow into the tissues. The drainage must be performed softly.harmoniously, rhythmically, and with supple hands. It is especially im­portant that the wrists remain loose. Hard massage or spasm-like ten­sion can give rise to local constriction of lymph capillaries with the for­mation of new infiltrations. The hands should be so supple and alive thatthe dry skin can be massaged. This is especially helpful during examina­tion of the patient." We would now like to deal with the whole-body treatment. As mas­sage therapists, we are familiar with complete treatments and holisticmedical care, even if we are compelled to carry out many partial treat­ments. We then apologetically say that the reflexes brought about by thetreatment do indeed have an impact on the whole person. New massagemethods are even developed within these time-saving techniques. When we carry out whole-body drainage, we are directly influencing50% of the total connective tissue in the body. Let us assume that the direct effect of MLD does not penetrate be­yond 2 cm below the skin surface. With a skin surface area of 2 squaremeters and a specific weight of the body of 1.2 (2000 x 2 x 1.2) 48 kg =(105Ibs). Taking the average body weight minus bones, we see that who­lebody treatment directly reaches about half of the total body tissue. In connection with Dr. VoddersMLD we would also like to mentionthe Arndt-Schulz biological principle. This says that small or weak sti­muli stimulate whereas strong stimuli inhibit or paralyse. To put the ef­fect ofMLD in a nutshell: MLD causes body fluid (connective tissue fluid, lymph and venousblood) to flow, removes waste products from the connective tissue, rec­tifies metabolic dysfunctions in the interstitium, supports the defencemechanism of the lymph system, balances the nervous system, relievescongestion and satisfies the therapist because she/he can achieve resultsand help people with a method whose effect can be precisely explainedand thus applied selectively. WhenManual Lymph Drainage is combined with other physical ther­apy methods, any circulatory treatment should be performed beforelymph drainage. In treating oedema, bandages of various types, stretchpositions, breathing therapy, a special diet, electrotherapy, and drugsare used. However, Manual Lymph Drainage is and will remain an in­dispensable part of oedema therapy e4]. 113
  • 109. C) APPENDIX
  • 111. Lymph drainage A new therapeutic method serving cosmetic care 1. Publication about Dr. Vodders manual lymph drainage, an originalwork from Dr. Emil Vodder, Paris 1936. The beauty of the face A poet describes the eyes as the mirror of the soul. In modern bodycare, the face could be called the mirror of health. The face not only re­flects our feelings of well being and sorrow or our character, but it alsoreveals our state of health, the balance of mind and body. The face is also more exposed than the body to the weather, i.e. wind,rain, and temperature changes. The face also "experiences" more of than the body; it is more "ex­posed". Thus in the morning, beauties notice the first signs of transitionin their faces, long before the body itself ages. With this shock begins thenever ending attempt to maintain beauty and radiance. Therefore it is not surprising that from time immemorial, we have en­deavoured to improve and brighten up the appearance of the face. It alsoisnt surprising that women who see their youth disappearing spend theirtime and money to try and stop this. Is it successful? . . . That depends onhow they invest their time and money. Yet there are many charlatans with bottomless pockets. Every day in­credible sums of money are given away for worthless skin care andbeauty products. Then it is not correct (and we should be clear about this) to cash in onthe inadequacies of the face like an ill person who believes he can get ridof his problems by taking tablets. It is just as useless to put a "youth" -cream on a sleepy face. These days, most of the beauty care products arefacade cosmetics. In other words, one cannot change the face with sur­face treatments: peeling of the skin with chemical products, just likesmoothing out wrinkles and strengthening the skin with certain cosmeticproducts are only a trick. Their effect only lasts for a short time becauseone doesnt get to the root of the problem. 117
  • 112. Is aging unavoidable? If the world continually develops, why cant we also benefit from theadvancements? Why is it that we cannot maintain perpetual youth? It isso nice to be young and supple, to shine with beauty and zest for life.Young and healthy people are simply successful in everything. Whytherefore does nature allow us to age? To find the answer we will take an investigative journey through thewondrous world of our bodies. The blood vessel system We begin our search in the heart itself, in a small vehicle that we willcall a "white blood cell". We can examine life more closely in the indivi­dual "factories" along the current in the path formed by our blood vesselnetwork. At first we are surrounded by numerous smaller boats: the red bloodcells which are loaded with oxygen, the fuel for all cell activity. The wa­ter in our current is called plasma and is yellow: it contains nutrients andwastes. Each heartbeat sends our small vehicle, in the incredible time of23 seconds, through the whole blood vessel system (arteries, capillariesand veins) until it has reached the heart again. The lymph vessel system Until now this was really unknown to the general public because circu­lation always referred to the blood circulation. A new system? Absolutely not, as the lymph system is the origin oflife, the Iymph* is the nutrient liquid for the very first collection of cells,just as it is for the living palace of millions of cells - the complete humanorganism. However this system was discovered relatively late: there are twonoteworthy 17th century scholars of the lymph system: Pecquet (1647)who discovered and named the cisterna chyli and the dane, Bartholinwho discovered the lymph system three years later. Thus we live in Iymph*, i.e. our tissues are washed in Iymph*. It sup­plies us with the life giving nutrients necessary for body development.118
  • 113. If we continue on our journey, we see how youth, life and death aredependant on lymph and its renewal. Our vehicle has now left the capillaries through a small secret doorand in this manner we can distinguish between the two circulatorysystems. Lymph is a whitish fluid. The flow in the lymph channels is sluggishand we glide calmly through because there is no pulsation here comingfrom the heart and driving us forward every few seconds. However westill move forward with the help of a carefully thought out valve systemthat prevents backflow: We pass thousands of filters until we reach thelarge lakes of the serous cavities. In this way we can visit all regions of thebody from head to feet, e.g. the labyrinth of the ear, the membranes ofthe brain and spinal cord, the pleura etc. We run into flooded regions(oedema and infiltrations) and dry areas where life functions slower andcells degenerate because the Iymph* was the source of their renewal. The lymph system therefore represents a type of sewage system,eliminating wastes produced by the working cells and carrying them toorgans which get rid of them - the lymph nodes. The lymph nodes We are concerned here with filters, whose function is to hold back anddestroy the harmful substances, poisons and bacteria. A lymph nodeconsists of adenoid tissue and continually produces white blood cells,like the spleen and tonsils. These cells defend the body against invasionand poisoning and their activity is heightened during infectious diseases.So what happens in the lymph system during an infection (e.g. during aheavy cold)? We experience a battle. The body reacts to the invasion ofbacteria in the nose with an immediate assembly of troops, a total secu­rity force. The mucous membranes swell up, the lymph vessels andnodes enlarge, the white blood cells destroy bacteria and take themaway. Generally the battle is finished in the lymph nodes, which can becompared to castles. It is fascinating to watch this process under the mi­croscope and gave rise to Claude Bernards conclusion: "Bacteria them­selves are not the decisive factor, solely the surrounding territory". We should be clear that a poor functioning lymph circulation lowersour defence which opens the door to every infection such as catarrh,chronic colds, sinusitis, sore throat, angina etc. Unfortunately, this con- 119
  • 114. dition of congestion which can be traced back to a worsening and stagna­tion of lymph, also has a detrimental effect on ones appearance. This isthe deeper cause of a series of cosmetic flaws such as swelling, redden­ing, puffiness, bags under the eyes, pimples, couperosis, etc. Stagnation of the lymph flow, therefore has catastrophic results forhealth and beauty: one must get the lymph circulation going again at allcosts and this is achieved with the help of manual lymph drainage. MLDcleanses the lymph, the swelling in the mucous membranes goes down­and consequently the cause of the problems is eradicated. The natural regeneration of skin through lymph drainage Before we go back to the heart, we conclude our investigative journeyby examining the skin. We see that the skin cells wear out and thanks toa process called mitosis, are constantly replaced by young cells. We have seen how the necessary, life-sustaining nutrients leave theblood with the help of osmosis, pass into the Iymph* and thus reach thecells. Assuming this exchange cannot take place, the lymph vessels be­come blocked with stagnant, old lymph. The blood flows, to no avail,past each little "secret door" and transports the nutrients to another lo­cation. This is how the body becomes poisoned by its own wastes. During my research work in the laboratories of the faculty in Copen­hagen (1922-24), under the direction of the renowned cancer researcherProf. Fibiger, the significance of the cell environment in lymph circula­tion for living, diseased, and dead cells was suddenly clear to me. I un­derstood clearly how the perpetual youth of the cell depends on this nuid(the Iymph*). Dr. Carrels experiments have supported my theories. He was able tokeep embryonic cells alive for over 10 years, whereas the nbrmal life ex­pectancy is only 4-5 years. This was possible thanks to the lymphatic mi­lieu which was changed every 2 days. Conclusion: If the milieu and cell activity stagnate then the cells willdegenerate, age and die. If the milieu is constantly renewed then lifenourishes and the cells divide. Then the wrinkled and tired skin canregenerate itself, it becomes fresh and elastic and the tired worn-out ap­pearance in the face disappears. A real metamorphosis is experienced,a natural regeneration that comes from within. Our new therapeutic method is therefore based on these facts.120
  • 115. Lymph drainage After many years of clinical experience and research, a rationalmethod of treatment has been successfully developed which enablesrenewal of the Iymph*, activation of the circulation, stimulation of cellactivity and regeneration of the facial tissue. Lymph drainage is a healthy, natural, painless and absolutely effec­tive method which gives a new basis to life, health and beauty. Original translation into german by Mechtild Yvon, M.A. Phil. ofVienna. We thank Mrs. Banniza of Menden for her great effort in procuringthis article. Nothing is added to this article. The special thing about it is that it waswritten 50 years ago. Vodders ideas of that time were proved correctthrough experiments in many ways. His manual techniques need noimprovement or further development. The method only needs furtherresearch of its actions. This is the task before us today and, at the sametime, a legacy left to us.* As this article was written, all bodily fluid excepting blood and cellular fluid was descri­ bed as "lymph". Now this is referred to in the nomenclature as "connective tissue fluid". 121
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