When Yulanda asks:

<<Thanks for this - but where are the milk reservoirs that the baby's 
gums
compress whilst feeding?>, Chrissy replies:

They don't exist anymore. ;-)


I personally would not be so hasty to conclude that. They are simply not perceived by all who deal with lactation in the same manner, that's all. And certainly, they are not perceived by all who deal with breast anatomy in the same way. In a personal communication with Professor Merlob from Israel, I mentioned this controversy, and he stated that he does not consider ultrasound to be the best medium with which to study or propose concepts about changed perceptions of the anatomy of the breast. 

Ultrasound has its particular (and very valuable) applications, but the microscopic views must also be taken into consideration. Another site on the U. of Western Australia has microscopic photos of several lactiferous sinuses in the non-pregnant breast. (If you want to see the photo, Google 'lactiferous sinuses', scroll down the references and click on 'Blue Histology', then click 'large images' (which is directly beneath the table of anatomical areas. Do NOT click on mammary glands.). Type in 'lactiferous sinuses', and '02' for the degree of magnification, then hit search, and you will see the photo.) Part of the problem we have in this regard is that there are not too many lactating breasts in the pool of cadavers or surgical specimens available for dissection!


Pat replies:

<I think that is the point.  There aren't any 'huge' reservoirs filling 
with
milk and waiting to be 'milked' (like the cow udder.)>

I don't think anyone has ever suggested they were 'huge' like the cow's udder(s), (which is what appears to be 'the bag' between the cow's rear legs, but actually consists of four large conjoined sections , which do each have a rather large 'cistern' in them.) Attached to each cistern is a teat, which also has a smaller hollow cistern inside of it, to contain milk. No one has ever suggested, even in the most cartoonish drawings, that the nipples, like teats, hold a reservoir of milk. I think far more people get this type of impression of the human nipple from familiarity with a hollow rubber feeding nipple than with a dairy animal's teat, though this is part of what I try to 'reframe' in the mind of parents when I am teaching them hand expression, or even latching. I tell them "There is no milk in the human nipple. You are not made like a farm animal. There is no 'farm animal forward' pulling involved." 

  <I would imagine the ducts dilate somewhat as the milk gets pushed out, but
not to extent that we see in old illustrations.>

Yes, the illustrators have often been much too 'generous' in their interpretation of Sir Astley Cooper's original diagram, and each new illustrator relies on the previous 'generation' of diagrams, or even just the general memory of them (hasn't each of us done this in drawing a hasty illustration??) in order to draw his newer illustration, and pretty soon, we end up with a pictorial version of the old 'telephone game'! 

But I still maintain that I have found the size of the sinuses in most pregnant or lactating breasts still large enough to be easily palpated by the experienced examiner, from the late third trimester onward, as evidenced by the expression of colostrum by compressing the proximal (closest to the body) portion.

Rachel says:

<Yulanda asks, where are the milk reservoirs that the baby's gums compress whilst feeding?  (Answer: They aren't there because Hartmann questions their very existence.)

I ask, where are those spongy yellow bunches-of-grapelike things
representing the milk glands as shown in the old Childbirth Graphics cloth
model?>

Again, perhaps it is the past cartoonish illustrations that have been at fault in trying to emphasize certain concepts for the sake of simple illustrations for the parents.

<Would that be fatty tissue around the milk-producing glands in
Hartmann's version?  According to Hartmann, the ropy things we've all been palpating seem to be glandular tissue.  The milk ducts would be scarcely palpable with the fingers in his version.  A challenging notion, but not impossible to believe>

<What still baffles me is how the drawings produced by examining cadavers can be so drastically different from Hartmann's portrayal of the breast tissue. . . . Have previous anatomists missed the mark so completely, thinking that . . . . adipose tissue is glandular, and glandular is ductal, and not seeing the actual ducts at all?  What about those who injected molten wax into the ducts, supposedly finding the reservoirs that way?  Were they actually finding the glands, which are not as discrete from the ducts as we have thought, based on the grape-like alveoli and the tube-like duct model?  This is very interesting indeed.>

Part of our own confusion probably comes from trying to charactarize the breast by one STATIC CONCEPT rather than as a DYNAMICALLY CHANGING ORGAN.(Not yelling, but I don't know how else to emphasize on LN.) The breast is enclosed in an envelope of skin, within which the TISSUES ARE CONSTANTLY CHANGING under the effect of hormones, even the hormones within each menstrual cycle, and, if Masters and Johnson are to be believed, even during sexual excitement. 

How a breast looks to an anatomist depends on the age of the particular woman, her genetic heritage, and probably most of all, her past and present reproductive stages. After conception, new glandular tissue gradually begins to replace many of the fat cells, so breasts from different trimesters of pregnancy, especially from the first to the second, when dissected under the microscope, would appear to have increasingly less fatty tissue and more glandular tissue. 

And the whole process is sort of the reverse during involution between reproductive events, and even moreso after menopause. I have found it fascinating to try to read some of the very basic histology literature. 
I do not have the exact citation with me, but this concept is very thoroughly explained by Russo and Russo in a text from the 1980's, which citation I can soon provide to anyone who wants to ask me for it personally. (Just because something was seen under the microscope over 5 years ago, or several hundred years ago (!) by a primary histologist doesn't make it an outdated concept.)

One of these days, I hope I can look up the actual work by Cooper, which to me seems like exquisite science for the techniques available in those days. I want particularly to know the reproductive stage of the woman whose breasts he dissected.

I have the utmost respect for Dr. Hartmann. From a old veterinary book I recently read, his name seemed to have been well known to dairy researchers years before it became known to those in the human lactation community, but I too feel very uncomfortable with the 'vested interest' of Medela which Rachel describes so well 

<The fact that their pump technology is so closely linked to this
anatomical paradigm is a barrier to my believing in it with all my heart. I have been totally turned off after seeing the model presented as a prelude in The Medela Symphony... As though the primary purpose of the research was to show that Medela's pumps are better than anyone else's, and not to illuminate the anatomy and mechanisms of breastfeeding.  I don't have any objection to Medela's pumps per se, and indeed, I recommend them often enough, but I don't yet believe they, or the Perth team, have a corner on the One True Way to understand the lactating breast.>

I am convinced that surgeons and pathologists and other radiologic techniques, such as galactography, must be involved in this current debate if we are to get a truly accurate idea about anatomy of the lactating breast. (However, I think it is unlikely that there will ever be any under research contract with Medela.)

Jean
*******************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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