1911 Encyclopædia Britannica/Mammary Gland
MAMMARY GLAND (Lat. mamma), or female breast, the organ by means of which the young are suckled, and the possession of which, in some region of the trunk, entitles the animal bearing it to a place in the order of Mammalia.
Anatomy.—In the human female the gland extends vertically from the second to the sixth rib, and transversely from the edge of the sternum to the mid axillary line; it is embedded in the fat superficial to the pectoralis major muscle, and a process which extends toward the arm-pit is sometimes called the axillary tail. A little below the centre of the glandular swelling is the nipple, surrounding which is a pigmented circular patch called the areola; this is studded with slight nodules, which are the openings of areolar glands secreting an oily fluid to protect the skin during suckling. During the second or third month of pregnancy the areola becomes more or less deeply pigmented, but this to a large extent passes off after lactation ceases. In structure the gland consists of some fifteen to twenty lobules, each of which has a lactiferous duct opening at the summit of the nipple, and branching in the substance of the gland to form secondary lobules, the walls of which are lined by cubical epithelium in which the milk is secreted. These secondary lobules project into the surrounding fat, so that it is difficult to dissect out the gland cleanly. Before opening at the nipple each lactiferous duct has a fusiform dilatation called the ampulla.
After the child-bearing period of life the breasts atrophy and tend to become pendulous, while in some African races they are pendulous throughout life. Variations in the mammary glands are common; often the left breast is larger than the right, and in those rare cases in which one breast is suppressed it is usually the right, though suppression of the breast does not necessarily include absence of the nipple.
Supernumerary nipples and glands are not uncommon, and, when they occur, are usually situated in the mammary line which extends from the anterior axillary fold to the spine of the pubis; hence, when an extra nipple appears above the normal one, it is external to it, but, when below, it is nearer the middle line. The condition of extra breasts is known as polymasty, that of extra nipples as polythely, and it is interesting to notice that the latter is commoner in males than in females. O. Ammon (quoted by Wiedersheim) records the case of a German soldier who had four nipples on each side. These nipples in the human subject are seldom found below the costal margin. In normal males the breast structure is present, but rudimentary, though it is not very rare to find instances of boys about puberty in whom a small amount of milk is secreted, and one case at least is recorded of a man who suckled a child. A functional condition of the mammary glands in men is known as gynaekomasty. (For further details see The Structure of Man, by R. Wiedersheim, translated by H. and M. Bernard, and edited by G. B. Howes, London, 1895.)
|(From A. F. Dixon, Cunningham’s Text Book of Anatomy.)|
|Fig. 1.—Dissection of the Mammary Gland.|
Embryology.—There is every probability that the mammary glands are modified and hypertrophied sebaceous glands, and transitional stages are seen in the areolar glands, which sometimes secrete milk. At an early stage of foetal life a raised patch of ectoderm is seen, which later on becomes a saucer-like depression; from the bottom of this fifteen or twenty solid processes of cells, each presumably representing a sebaceous gland, grow into the mesoderm which forms the connective-tissue stroma of the mamma. Later on these processes branch. The last stage is that the centre of the mammary pit or saucer-like depression once more grows up to form the nipple, and at birth the processes become tubular, thus forming lactiferous ducts. The glands grow little until the age of puberty, but their full development is not reached until the birth of the first child.
Comparative Anatomy.—In the lower Mammals the mammary line, already mentioned, appears in the embryo as a ridge, and in those which have many young at a birth patches of this develop in the thoracic and abdominal regions to form the mammae, while the intervening parts of the ridge disappear. The number of mammae is not constant in animals of the same species; as an instance of this it will be found that in the dog the number of nipples varies from seven to ten, though animals with many nipples are more liable to variation than those with few. When only a few young are produced at a time the mammae are few, and it seems to depend on the convenience of suckling in which part of the mammary line the glands are developed. In the pouched Mammals (Monotremes and Marsupials) inguinal mammae are found, and so they are in most Ungulates as well as in the Cetacea. In the elephants, Sirenia, Chiroptera and most of the Primates, on the other hand, they are confined to the pectoral region, and this is also the case in some Rodents, e.g. the jumping hare (Pedetes caffer). In the monotremes the mammary pit remains throughout life, and the milk is conducted along the hairs to the young, but in other Mammals nipples are formed in one of two ways. One is that already described in Man, which is common to the Marsupials and Primates, while in the other the margin or vallum of the mammary pit grows up, and so forms a nipple with a very deep pit, into the bottom of which the lactiferous ducts open. The latter is regarded as the primary arrangement. In the monotremes the mammae are looked upon, not as modified sebaceous glands, as in other Mammals, but as altered sweat glands. It is further of interest to notice that in these primitive Mammals the glands are equally developed in both sexes, and it is thought that among the bats the male often assists in suckling the young (see G. Dobson, Brit. Museum Cat. of the Chiroptera, London, 1878). These facts, together with the occasional occurrence of gynaekomasty in man, make it probable that the ancestral Mammal was an animal in which both sexes helped in the process of lactation.
For further details and literature up to 1906 see Comparative Anatomy of Vertebrates, by R. Wiedersheim, adapted by W. N. Parker (1907), and Bronn’s Classen und Ordnungen des Thierreichs. (F. G. P.)
Diseases of the Mammary Gland.—Inflammation of the breast (mastitis) is apt to occur in a woman who is suckling, and is due to the presence of septic micro-organisms, which, as a rule, have found their way into the milk-ducts, the lymphatics or the veins, through a crack, or other wound, in a nipple which has been made sore by the infant’s vigorous attempts to obtain food. Especially is this septic inflammation apt to occur if the nipple is depressed, or so badly formed that the infant has difficulty in feeding from it. The inflamed breast is enlarged, tender and painful, and the skin over it is hot, and perhaps too reddened. The woman feels ill and feverish, and she may shiver, or have a definite rigor—which suggests that the inflammation is running on to the formation of an abscess. The abscess may be superficial to, or beneath, the breast, but it is usually within the breast itself. The infant should at once be weaned, the milk-tension being relieved by the breast-pump. Fomentations should be applied under waterproof jaconette, and the breast should be evenly supported by a bandage or by the corsets. Belladonna and glycerine should be smeared over the breast, with the view of checking the secretion of milk, as well as of easing pain. But before this is done six or eight leeches may be applied. On the first indication that matter is collecting, an incision should be made, for if the matter is allowed to remain locked up in the breast tissue the abscess will rapidly increase in size, and the whole of the breast may become infected and destroyed. Supposing that, in making the incision, no pus is discovered, the relief to the vascular tension thus afforded will be nevertheless highly beneficial. The operation had better be done under a general anaesthetic, so that the surgeon can introduce a probe, or his finger, into the wound, breaking down the partitions which are likely to exist between separate abscesses, and thus enable them to be drained through the one opening. As the discharge begins to cease, the tenderness subsides, and gentle massage, or firm strapping of the breast, will prove useful. The general treatment will consist in the administration of an aperient, and, the tongue being clean, in prescribing such drugs as quinine, strychnia and iron. The diet should be liberal, but not carried to such excess that the power of digestion and absorption is overtaxed. During the early acute stage of the disease small doses of morphia may be necessary. When the tongue has cleaned, a little wine may be given with advantage.
Chronic Eczema around the nipple of a woman late in life, with, perhaps, localized ulceration, is known as Paget’s Disease. The importance of it is that cancerous infiltration is apt to pass from it along the milk-ducts and to involve the breast in malignant disease. Hence, when eczema about the nipple refuses to clear up under the influence of soothing treatment, it is well to insist on the removal of the entire breast. Sometimes this eczema is malignant from the beginning, being associated with the active prolifization of the epithelial cells of the milk-ducts, and with their escape into the surrounding tissues. The nipple is retracted in most of these cases, which, however, are not often met with.
Chronic Mastitis is of frequent occurrence in women who are past middle age. The part of the breast involved is enlarged, hard, and more or less tender and painful. It is sometimes impossible clinically to distinguish this disease from cancer. True, the tumour is not so definite or so hard as a cancer, nor is it attached to the skin, nor to the muscles of the chest wall, and if there are any glands secondarily enlarged in the arm-pit they are not so hard as they may be in cancer. But all these are questions of degree. It is, of course, highly inadvisable to leave it to time to clear up the diagnosis, for a chronic mastitis, innocent at first, may eventually become cancerous. If in any case the difficulty of distinguishing a chronic mastitis from a malignant tumour of the breast is insuperable, the safest course is to remove the breast and have it examined by the microscope. The suggestion, sometimes made, as to the preliminary removal of a small piece of the tumour for examination is not to be recommended.
A simple glandular tumour, fibro-adenoma, is apt to be found in the breasts of youngish women, who may possibly give an account of some blow or other injury; there may, however, be no history of injury. The tumour is smooth, rounded or oval, and lies loose in the midst of the breast; as a rule it is not tender. It is not associated with enlarged glands in the arm-pit. The tumour had best be removed, though there is no urgency about the operation, as the growth is absolutely innocent. There is, however, no telling as to what course an innocent tumour of the breast may take as middle age comes on.
Cysts of the Breast.—A galactocele is a tumour due to the locking up of milk in a greatly dilated duct. Other forms of cystic disease may be due to serous or hydatid fluid, or to thin pus, being surrounded by fibrous walls. Such cysts are best treated by free incision, and by passing a gauze dressing into their depths. If the tissue is occupied by many cysts, the whole breast had better be removed.
Cancer of the Breast may be met with in men as well as in women; in men, however, it is very rare. It is commonest in women between the ages of forty and fifty. It is sometimes met with in women of twenty; and the younger the individual the more malignant is the disease. Married life seems to have no effect as regards the incidence of the disease, but it often happens that a breast which gave trouble during the period of suckling becomes later the subject of cancer; in other cases there is a clear history of the attack having followed an injury. It is, thus, as if inflammatory changes in the breast were the direct cause of a later cancerous invasion. Though it is impossible to affirm that heredity has a great influence in the incidence of cancer, it is, nevertheless, remarkable that the members of certain families are unusually prone to the disease.
The chief feature of a cancerous tumour of the breast is its great hardness. The technical name for the growth is scirrhus (Gr. σκίρος, or σκίρρος, any hard coat or covering, stucco), from its stony hardness. The tumour consists of a dense framework of fibrous tissue, with groups of cancer-cells in the spaces. The malignancy of the disease depends upon the cells, not upon the fibrous tissue. In young subjects the cells predominate, but in old ones the contraction of the fibrous tissue throughout the breast compresses and destroys the cells, and this sometimes to such an extent that there is at last nothing left at the site but contracted fibrous tissue, all trace of malignancy having disappeared. This variety of the disease is found in old people, and is called atrophic cancer.
The cells of a cancerous breast are apt to be carried by the lymphatics to the lymphatic glands in the arm-pit, and by the bloodstream to the spinal column and to other parts of the skeleton, and sometimes to the liver, which thus becomes large and hard, or to the other breast.
As the fibrous tissue around the tumour becomes invaded by the new growth it undergoes contraction (much as a string becomes shorter when it is wetted), and as this shortening of the fibrous bands increases the nipple may be retracted, and the breast may be closely bound down to the chest-wall; and, further, the skin overlying the tumour may be drawn in towards the tumour so as to form a conspicuous dimple. Later, the nutrition of this patch of skin may be so interfered with that it mortifies or breaks down, and thus a cancerous ulcer is produced. This ulcer slowly spreads, and its floor is covered with a discharge in which septic micro-organisms undergo cultivation; in this way the ulcer becomes highly offensive. By the use of antiseptic lotions and a frequent change of dressings, however, all unpleasant smell can be checked or prevented. As the ulcer extends it is apt to implicate large blood-vessels, so that serious, and sometimes alarming, haemorrhages take place. And if the breast had previously been in pain, the bleeding is likely to give great relief. But repeated haemorrhages bring on increasing exhaustion, and thus materially hasten the end.
There is at present only one trustworthy treatment for cancer, and that is its free removal by operation. The entire breast and the nipple must be sacrificed. At the present day the operation itself is not a “dreadful” one. To be successful it must be very thorough, and it must be done early. The patient, being under an anaesthetic, feels nothing, and the subsequent dressings of the wound are attended with scarcely any pain. There need be but a couple of days of confinement to bed, and when the wound has soundly healed the patient may be encouraged to use her arm. Should there be recurrence of cancerous nodules in or about the wound, their removal should be promptly and widely effected. The writer has records of one case in which between the first operation and the last report there was a space of over twenty-nine years, and another of fifteen years. Each of these patients had one extensive operation, and four or five smaller operations for dealing with recurrences. Each of them, however, might be considered unlikely subjects for further return.
For a superficial cancer the X-rays may be of service, but many applications of the rays are likely to be needed, and the case may possibly refuse to yield to their influence, and, after loss of valuable time, the disease may have eventually to be removed by the knife. The great advantage which the treatment by the knife offers over every other method is that the growth can be cleanly, efficiently and promptly removed, and, with it, all the affected lymph-spaces, and the lymphatic glands which are secondarily implicated.
As regards the value of radium in the treatment of cancer of the breast, the high expectations which were somewhat widely associated with this newly-found element early in 1909 must be said to have been unjustified by any precise results. Injections of radium salts have been made into the substance of a cancer, and tubes of aluminium containing the salt have been introduced into the growth, but no deep cancer has thereby been cured. Radium has also been exposed again and again on the surface of the affected breast, but similarly with no great result. Unfortunately, whilst one is experimenting in the treatment of an operable cancer, the epithelial cells of the growth may be making their way towards distant parts, where no rays or emanations could possibly reach them. Whatever may be the future of radium as a therapeutic agent in the treatment of cancer of the breast, it is certain that, on the facts as known at the beginning of 1910, the only safe course is to remove the breast by direct operation, together with the associated lymph-spaces and lymphatic glands. And if this is done promptly and thoroughly cancer of the breast will come more and more into the class of curable diseases. (E. O.*)