Pathophysiology of lymph edema

Abstract

In a paper entitled “Lymphoedema: The case for doubt” (Brit.J. Plast. Surg. 21 (1968), 32–44) Calnan rejected the generally accepted pathophysiological basis of Lymphoedema. His arguments are:

The age of onset in primary lymphoedema. Calnan finds it difficult to understand why a single hypoplastic lymphatic trunk which has served for the efficient return of lymph for 15 to 20 years begins to fail in its job without any obvious cause. Still more difficult to understand for Calnan is the case of the much older woman who has successfully passed adolescence, pregnancies and a very active life of sport before lymphoedema appears.

Calnans next problem is female dominance in primary lymphoedema. According to him, the classical concept of lymphoedema does not account for this difference.

In 80 per cent of patients with primary lymphoedema the left leg is oedematous. The left common iliac vein is crossed by the right common iliac artery opposite the body of the 5th lumbar vertebra. According to Calnan the vein, which drains virtually all the blood from a leg, becomes compressed between artery and bone. Is “lymphoedema” in these cases an oedema of venous origin?

Sometimes lymphography shows normal lymphatics in patients with a clinically typical lymphoedema. How these cases can be explained?

Sometimes lymphography shows abnormal lymphatics in limbs free of oedema. How these cases can be explained?

At the time of radical mastectomy the surgeon may destruct the lymphatic pathways in the axilla completely and one would expect lymphoedema to follow. Yet in more than 80 per cent of patients there is minimal or no swelling. Why?

Calnans problems are analyzed and his questions are answered. The evidence shows that lymphoedema can be defined as the result of a low output failure of lymph flow in combination with a deficient extralymphatic mastering of stagnating plasma proteins.