Introduction: Breastfeeding and Survival
Even though philosophical and medical authorities explicitly promoted breastfeeding, a large proportion of infants were not breastfed by their mother. Infants not breastfed by their own mothers had diminished chances to survive. This was even more true longer ago (1), especially in summer, when bacterial growth was rapid in unrefrigerated milk. In Paris in 1899, Budin reported an infant mortality rate of 4.9% in breastfed and of 45.8% in bottlefed infants (2). Recommendations were given as general, ritual endorsement with little impact. A remarkable degree of ambivalence is revealed by the qualifying phrases and conditions: ‘if the mother’s health permits…’, ‘if she has enough milk…’, ‘if her husband permits…’, etc. Previous investigations clarified maternal and infantile medical causes and social factors associated with not breastfeeding. This article analyses how medical doctrines erected obstacles to breastfeeding, practically unsurmountable by most women.
Classic Theories of Lactation
Being ignorant of hormones and blood circulation, Greek scholars imagined a physical connection to transfer concocted menstrual blood to the breasts. The raw material for milk originated in the uterus. Hippocratic writers stated (5th century BCE) (3).
‘Milk is akin to the menses when the eighth month is gone and the nutriment passes over [to the breasts]’. Also, Aristotle (384–322 BCE) equalled milk with retained menstrual blood (4): ‘In [thirty] days after conception, the discharge [catamenia] no longer takes its usual course, but is turned towards the mammae, in which the milk begins to make its appearance’. Galen (129–210 CE) wrote (5) ‘While in the uterus, we are wont to be nourished by blood, and the source of milk is from blood undergoing a slight change in the breasts’, and believed a vessel existed to connect uterus to the breasts (6): ‘It was my special aim to tell the usefulness of the close relation between breasts and uterus… Only to the testes [ovaries] and breasts did [nature] bring [blood] not from vessels nearby, but from those at a distance. It is the length of time which the blood spends in the vessel conducting it that permits the perfect concoction of these and of necessity blood spends more time in longer vessels and the longer vessels are always those that come from a distance’. Galen’s teachings were transmitted into mediaeval medicine by Avicenna (11th century CE) (7): ‘During pregnancy, the blood which is otherwise discharged from the female at the time of menstruation becomes nutriment [for the embryo]’.
In the 13th century, the Franciscan scholar Bartholomäus Anglicus (1190–1250) wrote (8) ‘For aftir the burthe of a childe yif blood is not iwastid with fedinge, it cometh by a kynde wey into the pappis [breasts] and waxith whit by vertu of ham and taketh the qualite of melk… The pappes ben isette to the brest to be near to the herte and turne into the kynde of melk. For blood cometh by an holough veyne to the hearte and thanne to the brest’. The widely distributed women’s secrets, ascribed to Albertus magnus (1192–1260) (9) but compiled in the 14th century, specified: ‘The first thing that develops is a certain vein or nerve which perforates the womb and proceeds from the womb up to the breasts. When the foetus is in the uterus of the mother, her breasts are hardened, because the womb closes and the menstrual substance flows to the breast’.
Prevesalian Anatomy Persisted
Mondino dei Luzzi, pathologist in Bologna, dissected two female cadavers in 1315 and described ‘from the side of the uterus originate two vessels. One penetrates the abdominal wall [diaphragma ?] and ascends, the other ascends less hidden and close to the skin, until it reaches the breasts’ (10). Leonardo da Vinci, in his anatomical drawings, described ‘two creatures cut through the middle’ (11) and explained: ‘We shall make three figures of the female to show the womb and menstrual veins which go to the breasts… I display to men the origin of their second-first or perhaps second cause of existence’.
From Galen came the belief that the sperm is derived from the testes, the ‘first cause’, and from Hippocrates by way of Avicenna the idea that the soul, the ‘second cause’ is infused from the spinal cord. Therefore, Figure 1A shows two tubes in the penis. When printing disseminated anatomical knowledge, the vasa menstrualia assumed different shapes, were confused with the ductus thoracicus or with epigastric vessels, and sometimes became a product of sheer fantasy. Ascribed to Johannes Ketham (12), the fasciculus medicinae depicted in 1491 (Fig. 1B) ‘The female breasts are large to reduce the heat received from the heart… vessels ascend from the uterus to the breasts…’ The field surgeon Hans von Gersdorf stated in 1528 (13) ‘Between [uterus] and the breasts are the milk vessels and the menstrual vessels’. Walter Ryff’s anatomy of 1541 depicted and named the venae seminales candidae (Fig. 1C) (14). Padovan anatomist Andreas Vesalius dissected many human bodies and depicted the intra-abdominal vessels meticulously – his fabrica (1st edn. 1543) did not mention any connection between uterus and breast (15). However, Aristotle’s and Galen’s doctrine of lactation had made its way into the paediatric texts and remained highly influential well into the 19th century.
Leiden professor Herman Boerhaave, usually not afraid to attack traditional doctrines, described a ‘miraculous vascular connection’ (16), whereas his pupil Albrecht V. Haller referred to Vesal, who could not find these vessels (17): ‘moreover, there is a certain nervous sympathy between the breasts and the uterus’.
The condemnation of mothers who did not breastfeed started after the reformation (18). However, breastfeeding remained an exception among the wealthy. Defining the class mammalia, Linnaeus in 1758 abandoned Aristotle’s classification quadrupedia (19). In Germany, Rabenmutter became the favourite stereotype, unjustly attributed to the raven by Konrad von Megenberg in 1349: ‘The ravens throw quite a few kids out of the nest when annoyed by the trouble to bring them enough food’ (20). In the US, the La Leche League referred to women who chose not to breastfeed bad yuppie mothers (21).
‘Abstain Completely from Sexual Relations’
Derived from the classical theory, scientists prohibited intercourse during lactation, usually with Galen’s words (5): ‘I order all women who are nursing babies to abstain completely from sex relations. For menstruation is provoked by intercourse, and the milk no longer remains sweet. Moreover, some women become pregnant, than which nothing could be worse for the suckling infant. For in this case, the best of the blood goes to the foetus… Meantime, the blood of the pregnant naturally becomes less and of inferior quality, so that not only less, but also inferior milk collects in the breasts; so that if a nursing mother should become pregnant, I should strongly advise that another nurse should be procured, thinking and considering that her milk would be better in taste, appearance and odour’. Avicenna transmitted the doctrine (7) ‘The wet nurse should not allow coition, for this disturbs the menstrual blood and diminishes the quantity of milk and alters its composition, as shown by the change in odour. Moreover, she might become pregnant, in which case there would be a dual unpropituous influence’.
Practically, all authors from the 15th to 18th century reiterated the intercourse ban during lactation, with varying reasons: Augsburg city physician Bartholomäus Metlinger 1473: ‘very harmful’ (22); Frankfurt city physician Eucharius Roesslin 1513: ‘bad taste’ (23); Simon de Vallembert, physician to the Duke of Orléans 1565: ‘bad smell’ (24); Verona physician Omnibonus Ferrarius 1577: ‘odour deteriorates’ (25); Royal midwife Louise Bourgeois 1609 (26): ‘Above all, [lactating women] should beware of the loving mood: this happens often in good-looking women returning to their husbands, their milk is a real venom for the infants’. Zurich city physician Johann Muralt 1697: ‘disgusting impression’ (27); and the widely distributed Nurse’s Guide from London 1729 (28): ‘If a Nurse, by Frequent Intercourse with her Husband, should give her Foster-Child an ill-flavoured Milk, destitute of its fattest and richest Part, the purest Blood, of which it ought to be made, having been spent on the Parts serving to Generation’.
In the Scandinavian countries, the notion that breastfeeding women should abstain from sexual intercourse was introduced as late as the 17th century (29). In his famous book on childhood diseases (1st edn. 1764) (30), Uppsala Royal Physician Nils Rosén von Rosenstein adopted the prejudice: ‘She should not indulge in love, because the child suffers and the milk turns unhealthy and salty. If a married nurse desires intercourse with her husband, she is no longer capable to be a wet nurse’. As late as 1917, Pierre Garnier claimed that ‘copulation makes the milk serous, tasteless and yellowish’ (31).
Galen’s ban on intercourse isolated the mother, provided an alibi for paternal infidelity and made the infant its own father’s rival. To comply to the doctrine, the rich hired wet nurses and the poor took refuge in artificial feeding.