Clinical Anatomy 22:531–536 (2009)

A GLIMPSE OF OUR PAST

Historical Review of Breast Lymphatic Studies

HIROO SUAMI,1,2* WEI-REN PAN,1,2 AND G. IAN TAYLOR1,2
1
The Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Royal Melbourne Hospital,
Melbourne, Australia
2
Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Australia

The gross anatomy of the lymphatic system is one of the least studied areas of
anatomy, primarily because of the technical difficulties encountered in demon-
strating this almost invisible yet vast system. Similarly, there have been very
few studies of the gross lymphatic anatomy of the adult human breast. Previ-
ous studies used young pregnant female cadavers. When mercury was
injected into the lactiferous ducts or breast lymphatic channels, these cadav-
ers enabled early anatomists to see the breast lymphatics. Both Cruikshank
(1786) and Cooper (1840) located the axillary lymph pathway as well as
accessory pathways directly from the breast. Sappey (1874) concluded that all
lymphatics arising from the breast drained into the axilla via the subareolar
plexus. Current descriptions of the breast lymphatics may be traced back to
the diagram made by Poirier and Cuneo (1902). However, it is apparent that
this diagram is a composite of adult breast studies by Sappey, their fetal stud-
ies and even clinical feedback. This study provides an historical perspective of
the methods that have been previously used to study the lymphatics of the
breast and introduces an update on current investigative approaches. Clin.
Anat. 22:531–536, 2009. V 2009 Wiley-Liss, Inc.
C

Key words: history; lymphatic system; mercury injection; Gerota’s method;

breast cancer

INTRODUCTION literature. Hippocrates (460–360 B.C.), the Father of

The treatment of breast cancer has been one of the
most rapidly changing fields in surgery. Recent devel-
opments in the sentinel lymph node biopsy concept
are widely applied for the treatment of patients with
breast cancer, especially in the early stages (Veronesi
et al., 2003). The existence of cancer cells in the sen-
tinel lymph node is a useful indicator when selecting
patients who require axillary dissection (Giuliano et
al., 1994). However, the feasibility of the concept has
never been assessed anatomically, because there has
not been an appropriate method to delineate the lym-
phatic channels and very little is known about the
techniques used by early anatomists who demon-
strated the lymphatic drainage of the breast with
composite drawings. This study aims to record chron-
ologically the history of breast lymphatic studies and
to introduce the authors’ new technique for demon-
strating the lymphatic system in cadavers.
Since ancient times, descriptions of the lymphatic
system have appeared sporadically in the medical
Medicine, mentioned ‘‘white blood’’ in an axillary
node in his book Peri Adenon. In 1622, the Italian
anatomist Aselli was credited with the discovery of
the lymphatic system. By chance, while performing a
vivisection searching for autonomic nerves in a well-
fed dog, he discovered white cords in the mesentery.
He cut the cords and observed milky liquid emerging
and concluded the importance of these vessels in
Grant sponsors: The Jack Brockhoff Foundation, The Colonial
Foundation, The National Health and Medical Research
Foundation.
*Correspondence to: Hiroo Suami, E533, Medical Building,
Department of Anatomy and Cell Biology, University of Melbourne,
Grattan Street, Parkville 3050, Victoria, Australia.
E-mail: hsuami@hotmail.com
Received 16 March 2008; Revised 27 March 2009; Accepted 19
April 2009
Published online 30 May 2009 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20812

C 2009
V Wiley-Liss, Inc.
532 Suami et al.

that when mercury was injected it occasionally

passed into the breast lymphatics as well as the lac-
tiferous lobules. It is notable that Cruickshank
described both axillary and internal thoracic lymph
pathways. He published a comprehensive anatomical
book of the human lymphatic system but unfortu-
nately did not include diagrams of his findings
(Fig. 1).
Cooper (1840) published a book detailing the
anatomy of the breast region. In one chapter enti-
tled, ‘‘Of the absorbent vessels’’ he wrote ‘‘When the
gland is in a state of lactation they (lymphatics) are
readily injected and demonstrated.’’ He also used
pregnant female cadavers and injected mercury for
delineating lymphatic vessels (Fig. 2), describing an
axillary lymphatic route and several other accessory
routes including internal mammary and intercostal.
He hypothesized that if one lymphatic pathway was
obstructed by disease another adjacent detour route
would compensate by independently draining the
region.
The most significant contributor to our under-
standing of the anatomy of the lymphatic system
was Sappey (1874), a French anatomist, who pub-
lished an extensive treatise of the human lymphatic
system in his book Anatomie, Physiologie, Pathologie
des vaisseaux lymphatiques. He also used pregnant
female cadavers in his studies and his results, using
mercury injections (Fig. 3), have become the basis
of our current understanding of the cutaneous and
breast lymphatics. He described that the breast lym-
phatics originating as a dense network surrounding
the mammary lobules, then forming collecting lym-
phatic trunks that follow the mammary ducts centri-
petally to the subareolar lymphatic plexus. He con-
cluded that lymph drains from the breast to the axilla
via this subareolar plexus. Sappey (1874) formally
denied the existence of accessory lymph pathways
from the breast despite the previous works of
Cruickshank (1786) and Cooper (1840).

Fig. 1. Cruickshank’s mercury injection of the lym-

phatics in 1786.

relation to the absorption of nutrients. Aselli’s (1627)

achievements were published in his book De Lactibus
Sive Lacteis Venis 2 years after his death.
Nuck (1697) developed the mercury injection
technique for demonstrating the lymphatic system,
and for the next 2 centuries, mercury injection stud-
ies of the gross anatomy of the lymphatic system
flourished in human cadaver studies. It is probable
that Cruickshank (1786), disciple of William Hunter,
was the first person to describe in detail the human
breast lymphatics in a fresh female cadaver who had
died during childbirth. He expressed milk from the Fig. 2. Cooper’s mercury injection of the breast
breast to empty the lobules and then inserted a fine lymphatics from the nipple to the subclavicular lymph
glass tube into the lactiferous ducts. He reported nodes.
 Review Breast Lymphatics 533

Poirier and Charpy (1902) published a multivo-

lume anatomical atlas Traite D’Anatomie Humain in
which Poirier and Cuneo performed cadaveric studies
using Gerota’s method and summarized their find-
ings as well as anatomical and clinical literature at
the time in their chapter on the lymphatics. They
published a semidiagrammatic figure of the lym-
phatics of the breast and axillary glands (Fig. 4) and
the figure, redrawn by a medical artist, is still repro-
duced in a modern anatomical textbook today (e.g.,
Gray’s Anatomy; Standring, 2008). Although specu-
lative, it is possible that Poirier and Cuneo used Ger-
ota’s technique for their cadaver studies in fetuses
and superimposed this diagram on Sappey’s adult
breast image (Figs. 3 and 4).
Grant et al. (1953) investigated the breast lym-
phatics using surgically resected specimens instead
of cadavers. He injected Evans blue dye into the
breast of patients before undergoing radical mastec-
tomy. His results agreed with Sappey’s that the
lymphatics originating from breast parenchyma col-
lected in the subareolar plexus and then drained to
the axillary lymph nodes. As a result, he empha-
sized the importance of wide-skin resection over the
breast for surgical treatment of breast cancer.
Turner-Warwick (1959) approached mastectomy
specimens in much the same way. He injected vari-
ous combinations of dye and radioactive substances
into breast tissue to delineate the lymphatic path-
ways. He observed and photographed specimens
demonstrating direct lymph pathways from the
injection site to the axillary nodes without passing
through the subareolar plexus (Fig. 5). Using radio-
active colloidal gold, he also showed that the lym-
phatics from every quadrant of the breast could reach
the internal mammary lymphatics. Turner-Warwick

Fig. 3. Sappey’s diagrams of the breast lymphatics

of a pregnant woman; the subareolar lymphatic plexus
(above) and the mammary gland (below).

Gerota (1896), a Romanian anatomist, developed

a potential replacement method for mercury injection.
He mixed Prussian blue oil paint in turpentine oil and
ether and injected this mixture into tissue using a fine
glass tube. He also found the lymphatic route from
the mammary glands to the liver or subdiaphragmatic
nodes via the rectus abdominis muscle. Histological
examination was possible using Gerota’s method. Fig. 4. Poirier and Cuneo’s review diagram of the
However, this method used only child cadavers or breast lymph drainage. This diagram was composed of
fetuses because the injectant was not taken up by the anatomical and clinical findings from several investiga-
lymphatic vessels in mature cadavers. tors including Sappey.
534 Suami et al.

Fig. 5. A cleared mastectomy specimen injected preoperatively with iron-prus-

sian blue by Turner-Warwick. The dye demonstrated several lymph vessels
(between black arrows) directly from the injection site (IS) to the axillary lymph
nodes (white arrows). (From Turner-Warwick, 1959, Br J Surg 46:574–582, John
Wiley & Sons Ltd., reproduced with permission.)

pointed out the possibility that Sappey (1874) and
Grant et al. (1953) had mistaken the mammary duct
for lymphatic vessels by their nonselective injection
using mercury or dye, thereby overemphasizing the
role of the subareolar plexus. More recently, in con-
trast to Grant’s view of breast lymphatic drainage,
skin-sparing mastectomy by Toth and Lappert (1991)
became popular for the treatment of early breast
cancer cases.
Since Turner-Warwick’s report (1959), our under-
standing of the gross anatomical details of the
lymphatic drainage of the breast seems to have
paused because of the lack of suitable techniques for
demonstrating the vessels. However, recently, the
authors have developed a new reliable method for
demonstrating and recording the lymphatic anatomy
in fresh adult cadavers (Suami et al., 2005). A small
amount of 6% hydrogen peroxide is injected into the
dermis and subcutaneous tissue of the target area.
The oxygen bubbles inflate the lymphatic vessels
and, under a surgical microscope, the vessels can be
identified. The lymphatic vessels are distinguishable
from venules, because they have valves at short
intervals that give them a bead-like appearance and
they do not contain red blood cells. Depending on
the diameter of these vessels, a fine glass tube or a
30-gauge 1-inch needle or 24-gauge cannula is
used. The injectant is made up of lead oxide (P3O4),
powdered milk, and hot water. Lead oxide is a radio-
opaque, bright orange substance that facilitates dis-
section, and it is ground into fine particles and mixed
with powdered milk to keep in suspension. Injection
of the mixture is begun gently and slowly by hand
with a 1 mL syringe. Resistance in the syringe, leak-
age from the vessel at the injection point or drainage
from the tissue edge indicates the completion of the
injection. Once the injection of one vessel is com-
plete, the procedure is repeated for other similar
vessels in the study area. After completion of the
direct lymphatic injection, the results are photo-
graphed and radiographed. Finally, the lymphatic
vessels are traced retrogradely from each first-tier
lymph node in the axilla and color coded to illustrate
their relationship to each node.
Compared with the indirect lymphatic injection by
Nuck (1692) and Gerota (1896), this method has
the following advantages. (i) Lymphatic vessels are
injected directly using microsurgery techniques. (ii)
Results are recoded on photographs and radio-
graphs instead of a composite drawing. (iii) The
lead-oxide mixture solidifies so that each individual
lymphatic vessel can be dissected and, if necessary,
could be cannulated again more proximally to com-
plete the pathway of each vessel. (iv) Each lymph
vessel that enters a first-tier lymph node is then
traced retrogradely to define its draining territory to
the node. (v) Finally, the injected specimen can be
cross-sectioned into parallel slices and each placed
on its side and radiographed again, thereby demon-
strating the three-dimensional course of the lym-
phatic vessels.
The authors’ findings (Suami et al., 2008) in
their studies of the lymphatics of the breast (Fig.
6) describe the lymphatic vessels in the anterior
 Review Breast Lymphatics 535

Fig. 6. Direct radio-opaque injection of the anterior upper torsos (male: A and
C, female: B and D). (From Suami et al., 2008, Ann Surg Oncol 15:883-871, repro-
duced with permission.)

chest as originating from the subcostal, the lateral
border of the sternum and the areolar region.
These vessels radiate centripetally toward the axilla,
many passing through the breast tissue, without
passing through the subareolar plexus. These find-
ings as well as the work by Turner-Warwick (1959)
are discordant with the common belief that the
lymphatics of the breast drain into the subareolar
plexus before running toward the axilla as previ-
ously described by Sappey (1874).
The authors hope that the lymphatics of the
breast will be re-examined by anatomists in the
future and that updated information will provide a
better understanding and basis for rapidly progress-
ing breast cancer treatment.
ACKNOWLEDGMENTS
We thank Associate Professor Christopher Briggs,
the Department of Anatomy and Cell Biology, the
University of Melbourne and Mrs. Prue Dodwell for
their help with the preparation of the manuscript.
We are indebted to The Department of Anatomy and
Cell Biology, The University of Melbourne for their
continuous support.
536 Suami et al.
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