Early work in lymphatic mapping

We read the article by Drs Morton and Ollila (Surgery 1999;126:815–9) with great interest. We would like to amplify a historical aspect not highlighted in their review. While the credit for the term “sentinel node” is appropriately credited to Cabanas, the term “lymphatic mapping” should likely be credited to Braithwaite. In 1923, Braithwaite published a paper evaluating the flow of lymphatics near the ileocecal valve, using indigo carmine, in the British Journal of Surgery. While he was attempting to find a relationship between appendicitis and duodenal ulceration (“Valentino” appendicitis), this seems to be the first use of vital dye for “mapping.” Further, stimulated by this work, other vital dyes were evaluated in the first half of the century. Pontamine sky blue was used for mapping of lymphatic drainage intra-operatively as early as 1950. ^{,  ,  ,}  The toxicity, as evaluated in a report in Science, was low. Intraoperative node mapping was evaluated in preclinical models and as an aid in finding the thoracic duct throughout the 1950s. ^,  Clinical experience with the mapping techniques for carcinomas of the stomach and lung suggested its use as an aid to visualize nodes for complete lymphadenectomy. ^,  The use of the vital dyes was not aimed at a specific lymph node, but visualization of all nodes draining the organ. This was in keeping with a lymphatic permeation theory of nodal dissemination from solid tumors commonly held at the time. Their writing did not suggest that a “sentinel node” existed, which would have to wait for the seminal work of Cabanas and Morton.