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WiltlingcrTextbook of Dr. VodelersManual Lymph DrainageVolume I: Basic Course
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Textbookof Dr. VoddersManual Lymph Drainag,eVolume 1: Basic CourseBy GUnther Wittlinger t and Hildegard WittlingerPreface ...
CIP·Tilelaurnahme der DeuIS(:hen BibliolhekTextbook or Dloc10 Ir "odders manual lymph drainage. -Heidelberg: Haug.  DI. Au...
Dedicated to our esteemed teachersEstrid Vodder and Emil Vodder   t
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Table of ContentsForeword to the first english edition . . . . . . . . . . . . . . . .   10Foreword to the second revised ...
5. Effect of MLD on blood capillaries and connective tissue .   51        a) Structure and function of blood capillaries  ...
Iontophoresis . . . . . . . . . . . . . . . . . .       80      Stress and Dr. Vodders manual lymph drainage           81 ...
Foreword   The following preface was written by Dr. Emil Vodder, creator of theManual Lymph Drainage method.   Although my...
the newly discovered vessels "vasa serosa" and the lymph nodes "glan­dulae aquosae". As a favourite of Queen Christina of ...
when he received the Nobel Prize in 1912 for his research on the cultiva­tion of living cells. This was an exciting period...
syndrome? This hypothesis has since been substantiated a thousand tim­es over by such treatment, which has no side-effects...
treatment". I had written an article in French which appeared in the Pa­risian journal "Sante pour Tous" ("Health for Ever...
nutrients and vital substances must flow throughout the lymph interspa­ces by way of a "transit stretch" to the cells.   T...
sage techniques are much too forceful to allow drainage in the intersti­tium and may hinder transport (lymph obstruction)....
mune system maintains a huge arsenal of white blood corpuscles. A per­son weighing 70 kilograms has an average of    26 bi...
Foreword to the 2nd revised English Edition     Rapid scientific progress in the field of lymphology has made it neces­sar...
Course of study in manual lymph drainage (MLO)                              for beauticians  Training in manual lymph drai...
Weekend courses are also held for therapists with the aim of promo­ting continued training. Good technique is decisive for...
Drainage in Walchsee, which was established in 1972. The Dr. VadderSchool founded at the same place teaches the unaltered ...
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A) Theoretical Section
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Mode of action of manual lymph drainage               a) EtTect on the autonomic nervous system    The diagram to be drawn...
functions of the body. If the hypertension of many of our clients were notcaused by the subconscious, they could conscious...
b) Effect on the reflex pathways [3]   The nerves known as nociceptive fibres transmit pain-causing stimulifrom the periph...
the beginning and at the end of a stroke, but not to the stroke itself.Thus, it is continuously excited by MLD, since the ...
Thus, a person contracts measles only once in life because the body isimmune after the disease has abated. Immunity agains...
in the lymph vessels and lymph nodes there is a special defence reactionthat results from the synthesis of specifically ac...
is known in birds as the bursa of Fabricus, a lymphoid structure near thecloaca. This gland has not been found in man, and...
We also know through observation that we influence immunologicalevents and that the treatment of mucous membranes with MLD...
vessels determines the pulsation rate and thus the transport rate of thelymph. Stimuli produced by:a) Movements of the ske...
fluid, we speak of a circulatory system. Typically, the fluid flows throughsharply delineated channels, tubes or vessels. ...
stretching sti muli increase the "pulse rate" of the lymph sections .Smooth muscle cells, such as those in the vessel wal ...
on the volume of water to be removed . The drai nage or drain plan chan­ges, depending on the terrain and the stratificati...
mast cells and fat cells . The migratory cells of the connective tissue areable to detach themselves from the tissue matri...
b) Function   Connective tissue is an organ and as such has many functions and ca­pabi lities. I t is the vehicle of the u...
connective tissue . The calcium is stored in the form of calcium phos­phate and calcium carbonate molecules . Evolution ha...
c) Connective tissue cells    Con nective tissue conta i ns cells that not only produce collagen andelastic fibres but als...
When we take a closer look at the liquid, we find i t consists of 5%blood , 15% connective tissue fluid and 40-45% intrace...
b) Circulation   The left side of the heart pumps oxygen-rich blood through arteries,wh ich branch i nto smaller arteries,...
the lymph system , are designated lymph-obl igatory loa d . I ncl uded areproteins, immobile cells, cell fragments, waste ...
Efferent lymph vessels            Capsule     Trabecula   _--j���;:::Marginal sinus     �������or cortical sinus -        ...
There are more than 600 lymph nodes in the body , about 1 60 i n theneck region alone [23] . Lymph nodes not only bind, at...
Summarizing, the functions of the lymph nodes are:a) biological filter,b) concentrating lym ph ,c) immunological function ...
Table I : Defence areas (after BrclUs: from TischendOlf, F. , Lymphatisches System .Neuere Erkenntnisse liber d i e funkti...
III. Defence area: Wall of the upper tru n k with extremities     Boundaries: j ugular fossa, clavicle , middle of the nap...
the lymph vessels , the pressure difference created i n the thorax bybreathing, the movement of the skeletal m uscles , pe...
of diffusion i ncreases as the square of the distance . Therefore diffus ionrequires short distances if it is to effective...
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  1. 1. WiltlingcrTextbook of Dr. VodelersManual Lymph DrainageVolume I: Basic Course
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  3. 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. 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. 5. Dedicated to our esteemed teachersEstrid Vodder and Emil Vodder t
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  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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  23. 23. A) Theoretical Section
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  25. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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