Standing on the Shoulders of Giants

In response to the receipt of the first Lifetime Achievement Award from the Academy of Breastfeeding Medicine in September 2006, I was invited to make a few remarks a year later (the necessary recovery time from such a surprising and shocking experience) at the Academy meetings in Austin, TX in 2007.

Standing on the Shoulders of Giants, I thought best explained the experience. I did not invent this phrase. In fact it was first used by Aristotle, and some think by Plato, but it is well documented historically in Isaac Newton's writings. He said in fact: Pigmaei gigantum humeris imposite plusquam ipsi gigantes vident. “If I have seen farther, it is by standing on the shoulders of giants.”

He further explained “Plato is my friend. Aristotle is my friend. But my greatest friend is truth.”

What follows is not an anthology of giants. It is not even a complete historical review of giants. I began my search looking for the great people who had contributed to our knowledge of breastfeeding and human lactation, the giants of the field.

Historically it is probable that Eve (of Adam and Eve) breastfed Cain and Abel. Actual writings were not found however until about 360 BC from the sand script of Hippocrates, who said: “one's own milk is beneficial, others harmful.” Aristotle noted in about 320 BC, “there is a reason behind everything in nature.” Thus began our search to understand the content of human milk and the science of lactation.

There is no written record of infant feeding from the ancient time until the Renaissance, when Bagellarous in Padua, Italy wrote “The Rules for a Good Wet Nurse.”

The Dowager Countess of Lincoln wrote in 1662 “The Duty of Nursing” when she realized that the loss of her 19 infants was due to the fact she did not breastfeed them. She breastfed only one son, who was the only survivor. She commanded all mothers to breastfeed regardless of their social status.

The National Convention of France wrote laws in 1793 for wet nursing and support for breastfeeding mothers. Sir Ashley Cooper published the first scientific works in 1840 describing the let down reflex and the relationship between the mother's attitude and the quality of her milk. Human milk was first identified as an important nerve food by A.V. Meigs, MD, in 1884. In 1888 the American Medical Association could not agree on the best formula but was against wet nursing. “The Nursling,” which encouraged breastfeeding by all possible means and provided mothers with advice and help, was published in 1895 by Pierre Budin in France.

The exploration of human milk did not begin scientifically until the 1930s. Dr Paul Gyorgy was studying the B vitamins in the 1930s and 1940s, publishing significant findings in human milk. He became an outspoken advocate of breastfeeding in spite of working with formula company grant money. A German anatomist did seminal work on the anatomy of the breast in various stages of lactation published in Handbuch der Mikroskopischen Anatomic des Menschen in Berlin in 1957. A.T. Cowie wrote the Physiology of Lactation in 1971, while Vorherr published The Breast: Morphology, Physiology and Lactation in 1974. Derrick Jelliffe and his wife E.B. Patrice Jelliffe edited a symposium called the Uniqueness of Human Milk in 1971.

As I reviewed the long list of modern scientists investigating breastfeeding and human lactation I realized there were three contemporaries upon whose shoulders I had been standing since my residency at Yale in the 1950s. Dr Edith B. Jackson had received a federal grant in 1945 to establish a perinatal unit at Yale that would give the birthing process back to women. Her program began with birthing education: childbirth without fear Grantley Dick Reed style. She added rooming-in to the program, the first in the nation, and established a breastfeeding preparation and support program. All pediatric residents were assigned to cover the Nursery and make home visits in a car belonging to the Department to be sure breastfeeding succeeded later, following discharge from the hospital. I was honored to serve as one of Dr Jackson's chief residents. Meanwhile, Niles Newton was working toward her PhD in Pennsylvania studying the effects of oxytoxin on the human body and especially the breast. Her elegant writings on female physiology caught my eye as they established the scientific explanations for what was being described in Dr Jackson's clinical observations. The classic article “Management of Breastfeeding” was published in JAMA in 1953 by Dr Jackson and her students based on years of careful observation and clinical management of hundreds of nursing mother/baby dyads.

There were many laboratory scientists adding their piece to the puzzle of human milk and the hormones that controlled its production and release. The third giant upon whom I relied to achieve sufficient vision to see through the crowd of clinicans in the field was Dr Marshall Klaus. He was a respected neonatologist who had published the first neonatology textbook on the management of the sick neonate and was recognized as a neonatal physiologist.

In his observations of sick neonates he documented the behavior of the mothers of these fragile infants. He shared these observations in a text called Parent-Infant Bonding. This began a fire storm of discussion about mother-infant relationships that eventually confirmed breastfeeding as the ultimate relationship. It gave scientists license to explore the wider impact of breastfeeding on both mother and infant.

It is clear to me that as we each stand on the shoulders of our chosen giants in the scientific community we can indeed see more clearly in our path to discovery.

There are many gaps in this historical review. There are greater gaps in this commentary of giants. There are no gaps in my conviction, however, that none of us moves forward without the foundation of the work of others. And none of us sees above the horizon unless we can stand on the shoulders of giants.

And it is by standing on the shoulders of giants that some have indeed seen farther.