SPECIAL COMMUNICATION Manual Techniques Addressing the Lymphatic System: Origins and Development Bruno J. Chikly, MD, DO (France) umerous articles have been published describing the educator Johann Guts Muths developed a system of thera- Nscientific discovery of the lymphatic system, but few peutic gymnastics designed to maintain physical condition of these articles have focused on the origin and development and health.6 He was soon followed by fellow German physical of manual techniques addressing this complex system of educator Friedrich Ludwig Jahn, who created a gymnastics vessels, valves, nodes, and organs.1 These manual tech- system called turnen, which can be roughly translated as niques—like knowledge about the lymphatic system itself— “movement.”7 evolved late in the history of medicine. Also during the early 1800s, Pehr Henrik Ling, a Swedish Early civilizations did not make a clear distinction between instructor of gymnastics, used anatomic and physiologic prin- lymph and blood. Nevertheless, some of these civilizations, ciples to restructure the gymnastics system developed by notably those in Sumer and Babylonia (both in modern-day Muths. Ling developed the system of massage and rhythmic Iraq), Egypt, India, and China, had elementary notions of a movement called the “Sweden movement treatment,” also “white blood.”2 This substance may have been chyle, the post- referred to as “medical gymnastics” or the “Ling system.”8 prandial whitish lymph that carries lipids of the alimentary Ling suffered from chronic health problems, including tract.2 rheumatism. He discovered that his daily regimen of exercise The ancient Greeks also observed some elements of the and manual therapy had a beneficial effect on his health. In lymphatic system, most likely the lacteals, the milky lymph ves- 1804, Ling established himself in Lund, Sweden, as both a sels that carry chyle.3 In addition, they probably observed the fencing master and teacher of medical gymnastics.9 In 1813, the thoracic duct in animals.3 However, like other early civiliza- Royal Gymnastic Central Institute (now the College of Phys- tions, the Greeks failed to clearly differentiate lymph from ical Education) in Stockholm, Sweden, adopted his method, blood. Therefore, it is highly unlikely that manual lymphatic and in 1831, Ling was elected as a member of the Swedish techniques would have arisen in these civilizations. General Medical Association, the main professional organi- It was not until the 1600s that investigators clearly iden- zation for medical practitioners in Sweden.8 Today, Ling is tified the lymphatic system. The Italian surgeon and anatomist known as the father of modern massage and physical therapy. Gasparo Aselli published the first scientific description of the In 1851 in England, Mathias Roth, MD, published the lacteal vessels in dogs in 1622.4 The Swedish anatomist Olof first book written in English on the Ling system.10 Dr Roth Rudbeck demonstrated the passage of the lymphatic vessels trained Charles Fayette Taylor, MD, from New York, who of the mesentery into the ductus thoracicus in the 1650s, introduced the Ling system in the United States in 1858 with proving that lymphatic circulation is an integrated system the help of his older brother, George H. Taylor, MD.10 Dr that is separate from blood circulation.5 George Taylor wrote the first American book on the Ling As knowledge of the lymphatic system began to grow, so system, Exposition of the Swedish Movement Cure, in 1860.11 did interest in combining therapeutic techniques with body The Ling system of medical gymnastics consisted of (1) the movement—though, for many years, researchers made no hygienic aspect, which combined muscle strengthening with connection between body movement and the lymphatic general physical education, and (2) the medical aspect, which system. At the beginning of the 19th century, German physical focused on cures for physical ailments.8,11 The system used both active and passive motion. The practitioner-induced pas- sive motion, now widely known as Swedish massage, con- sisted of the application of pressure in long, firm motions From the Medical Faculty of Paris, Dr Chikly is an associate member of the along muscles, as well as clapping, cupping, effleurage, friction, American Academy of Osteopathy, a member of the International Society of pétrissage, tapotement, and vibration.8,11 Lymphology, and director of the Osteopathic Lymph Treatment seminars of None of the manual techniques developed by Ling specif- International Health and Healing Inc. He graduated from the European School of Osteopathy in Maidstone, England. ically addressed the lymphatic system, however. In fact, many Address correspondence to Bruno J. Chikly, MD, 28607 N 152nd St, of the Ling techniques may be contraindicated for patients Scottsdale, AZ 85262–6939. with edematous conditions, as suggested by recent research by E-mail: [email protected] Eliska and Eliskova12, who found that peripheral lymphatics Chikly • Special Communication JAOA • Vol 105 • No 10 • October 2005 • 457 SPECIAL COMMUNICATION are damaged by high-pressure massage. In their study, Eliska nerves, but have we any evidence that they are of more vital and Eliskova exerted pressures of 70–100 mm Hg for periods importance than the lymphatics? ... the system of the lym- of 1, 3, 5, and 10 minutes to both canine subjects (n=4) and phatics is complete and universal in the whole body.”16,17 He human subjects (n=2).12 The researchers detected destruction also wrote, “We are admonished in all our treatment not to of lymphatic vessels in skin biopsies, especially in cases of wound the lymphatics, as they are undoubtedly the life giving lymphedema and chronic postthrombotic venous edema.12 centers and organs. Thus it behooves us to handle them with The researchers also found that high-pressure massage caused wisdom and tenderness ... your patient had better save his some destruction of lymphatic vessels in life and money by passing you by as a nonedematous canine subjects (n=8) and failure, until you are by knowledge qual- human subjects (n=6). ified to deal with the lymphatics.”14,15 In addition, he stressed, anything that is Andrew Taylor Still’s Influences on retained in the lymphatics longer than Lymphatic Techniques necessary results in “fermentation, fever, Andrew Taylor Still, MD, DO (Figure 1), sickness and death.”15,19 announced the tenets of osteopathic Dr Still even speculated on a rela- medicine in 1874. Armed with a pro- tionship between lymph and the reab- found knowledge of human anatomy sorption of cerebrospinal fluid. He and physiology, Dr Still developed a wrote, “The lymphatics are closely and medical system designed to facilitate nat- universally connected with the spinal ural healing processes by finding and cord and all other nerves, long or short, correcting anatomical deviations that universal or separate, and all drink from interfere with the free flow of blood and the waters of the brain.”14,15 This pro- lymph and with the so-called “nerve posed relationship, in which cere- force” in the body.13 brospinal fluid is reabsorbed by the Although European traditions influ- lymph, has been supported by recent enced health and fitness in the United Figure 1. Andrew Taylor Still, MD, DO, first research.20 States from the early to middle 19th cen- proposed the tenets of osteopathic medicine Dr Still did not emphasize descrip- tury, Dr Still developed his tenets with in 1874. Image courtesy of Still National tions of his techniques of osteopathic no influence from the European tech- Osteopathic Museum, Kirksville, Mo. manipulative treatment (OMT) in his niques of Ling or other practitioners of writings. Although he did discuss a medical gymnastics. However, Dr Still did critically evaluate number of his techniques in The Philosophy and Mechanical several other medical theories that were then being investi- Principles of Osteopathy,16 he had copies of this book recalled for gated, such as bonesetting, eclecticism, Grahamism, home- fear that people would use it as a “how-to” manual (J.L. Dickey, opathy, hydropathy, and magnetic healing.13 These evalua- DO, oral communication, October 2005). The book was repub- tions helped Dr Still separate more effective from less effective lished in 1986 by Osteopathic Enterprise of Kirksville, Mo. techniques as he developed his original system of healing. In Rather than advocate specific osteopathic manipulative (OM) 1892, after achieving great success with his manual techniques, techniques, Dr Still expected osteopathic physicians to use Dr Still founded the American School of Osteopathy (ASO), their extensive knowledge of anatomy and physiology and now called the Kirksville College of Osteopathic Medicine of their clinical experience to find the best osteopathic approach A.T. Still University of Health Sciences in Missouri. for each patient. Nevertheless, several descriptions of Dr Still’s Dr Still created a multidimensional approach to manual lymphatic techniques can be found indirectly in the osteo- medicine, in which for the first time, the lymphatic system pathic medical literature.18,21,22 held an important place—though for him the lymphatics were A description of one technique attributed to Dr Still is still a “mystery to solve.”14,15 Dr Still admitted, “Possibly less found in an undated article by Charles F. Haverlin, DO,21 a stu- is known of the lymphatics than any other division of the life- dent of Dr Still’s. The article, which purports to describe “orig- sustaining machinery of