ANTENATAL CARE. 35

<diagnose it in the absence of a history of severeattack and never for right iliac fossa pain only.

VISCEROPTOSIS.The last subject I will mention is visceroptosis,

.and this will, perhaps, gently lead the way forDr. Crichton Miller, for many of these cases haveneurasthenic associations. By visceroptosis I mean.a condition of undue mobility of the abdominalorgans associated with pain and disordered action-of the stomach and intestines. It is almost confinedto women and is undoubtedly accompanied by,.and probably the cause of, a great deal of invalidism.A great stimulus has been given to the study of

visceroptosis by the exact method of observation,obtained by X ray examination after a barium meal,and the difficulty we had to contend with at firstwas that the normal was not properly known andmany variations from the normal were consideredpathological, that now, thanks to the researches ofDr. J. A. Ryle and others, we know to be com-patible with perfect function. We have now given-up believing that because a patient's hepatic flexureis normally below the level of the iliac crest in the,standing position that any harm need result, andthe normal haustrations of the transverse colonare no longer believed to be evidence of " catarrh."A stomach may be hypertonic or hypotonic andstill be normal for that type of individual.

This change of opinion has necessarily been-followed by a change in our practice, and operationsfor reefing and suspending the stomach are practi-,cally abandoned, and I hope that fixing the ascend-ing colon, short circuiting the colon, and excision ofthe colon for stasis will soon be abandoned also. Wemust remember that all the abdominal organs shouldbe capable in health of some degree of movement,and the fixation of, say, a kidney or the caecum iscontrary to the laws of nature and is, therefore,wrong in principle.

I believe we shall agree sooner or later thatsoperations to fix what should be mobile organs arenot successful, and that if operations must be donethe indication is rather to free organs abnormallyfixed, say, by adhesions, than to fix abnormally free.

(The opening remarks on the Mental Aspect of thequestion will be published in our next number.-ED.)

DURING October there was a goodly list ofnew subscribers to the POST-GRADUATE MEDICALJOURNAL, including, in addition to those residentin Great Britain and Ireland, others practising inCanada, and in America, in India, South Africa,Egypt, New Zealand, and no fewer than eight inBurma. One applicant writes from Ontario:" I am glad to know of all the possibilities of post-graduate studies, as I was contemplating crossingthe Atlantic for some post-graduate work somewherein Britain. ... I am intensely interested in thefact of the arrival of the JOURNAL, and shall lookforward to each number, which will make me moreconversant with the possibilities of certain coursesin the Old Land."

ANTENATAL CAREAS IT AFFECTS THE CHILD IN UTERO.*

BY

THOMAS WATTS EDEN, M.D. EDIN.,F.R.C.P. LOND., F.R.C.S. EDIN.,

CONSULTING OBSTETRIC PHYSICIAN, CHARING CROSSHOSPITAL, LONDON.

IT is universally accepted among us that thecare of infants and young children is one of thechief concerns of the State and of society. Publicinterest in the matter has been one of the mainforces behind those developments which, in thelast 25 years, have brought down our infantmortality-rate from 154 to 75 per 1000. I amasking you on this occasion to consider to whatextent we as medical practitioners are also con-cerned with the well-being of the child beforebirth. French obstetricians have for many yearsbeen much more concerned about all matterspertaining to infant mortality than we have, onaccount of their falling birth-rate, which has nowreached a point at which the depopulation of thatcountry may be said to have commenced. Mlanyyears ago Adolphe Pinard pointed out that inreality the preservation of child life must beconsidered in relation to three periods.

(I) The pre-conceptional period, in which theseed to be sown and the soil in which it is togerminate are the elements concerned; (2) theintra-uterine period, in which development is carriedfrom the blastomere stage up to the birth of thefully developed infant; (3) the postnatal stage.

It is Pinard's second period which concerns us-viz., that in which the child is developing in theuterus ; this period is under the care of the obstetricdepartment of medical practice. It is, therefore,part of our duty to consider whether there is any-thing we can do, and if so what, to ensure that theintra-uterine child is given the best chance ofcompleting its development and entering upon itsseparate existence under the most favourablepossible conditions. Antenatal work should notbe regarded only as a maternal safeguard, although,of course, its primary object is to ensure that theexpectant mother gets through her pregnancy withthe minimum of risk, and that she enters uponher labour under the most favourable obstetricalconditions.The question I am asking you to consider is to

what extent can antenatal care of the motherinfluence the well-being of the child in utero,Can we in any degree safeguard it against therisks of intra-uterine death or against prematureexpulsion, either when non-viable or later onwhen viable but heavily handicapped by pre-maturity, or from grave defects of development,

* Post-graduate Lecture delivered at the Prince of Wales'sGeneral Hospital on July 19th, 1926.

copyright. on January 4, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.2.15.35 on 1 Decem

ber 1926. Dow

nloaded from

ANTENATAL CARE.

or from transmitted intra-uterine disease, or fromthe perils of the birth process ? We have, perhaps,in the past been too much inclined to wash ourhands of all responsibility for the child until it isborn. We have considered its fate as lying in thehands of the two great forces which control develop-ment-viz., heredity and environment-forceswhich may well at first sight appear to be beyondour control. Heredity we must not stop to con-sider; environment, on the other hand, we shouldcertainly consider carefully, making use of theterm in its broadest possible signification.

Let us first of all consider what are the presentchances of the child completing its intra-uterinedevelopment and being born alive. It may becut off either by miscarriage or by still-birth;and further, if born alive, it may be born in acondition which renders its survival impossibleor at the best a matter of great uncertainty.As regards the frequency of miscarriages, there

are, of course, no official figures in this or anyother country. Some years ago my colleague,Dr. Amand Routh, attempted to estimate thefrequency. of miscarriages, partly from the expe-rience of several clinical observers, and partly fromreturns obtained from certain cities in the U.S.A.His figures indicated that almost one in five of allpregnancies terminated in miscarriage. If thisfigure is to be accepted for our own country it wouldfollow that in England and Wales in the year 1924something like 190,000 pregnancies terminated inmiscarriage. I do not suggest that we shouldaccept this figure without reservation, but there canbe no doubt that miscarriage is a very frequentoccurrence.

Regarding still-birth, there is information avail-able in this country, but it is limited. We know thenumber of still-births notified under the Notificationof Births Act, but no information as to the causeof death is given for still-births at all. Accordingto the report for 1924 of the Chief Medical Officerto the Ministry of Health, over 25,000 still-birthswere notified in that year. This corresponds toa rate of 3-3 per cent. of live births.In France, in the year 1922, according to

Couvelaire, the proportion of registered still-births(and only those are included which had passed thesixth month) amounted to 44 per 1000 live births.The same author shows that in France it is in thegreat centres of population that the highest still-birth-rate is found; Paris had a rate in that yearof 93 per 1000; a group of large towns a rate of69 per 1000; rural departments only 26 per 1000.It is, therefore, clear that a very large wastage offcetal life occurs from miscarriage and fromstill-birth.

Foetal death is, however, not the only considera-tion to be borne in mind. Many infants bornalive die in the very early days of the-neonatalperiod from injury received in labour, fromprematurity, from disease, or from debility ofunknown origin.

Ballantyne divided the duration of intra-uterine life into three periods, and it will be a help.to us to make use of his classification. The threeperiods were: first, the embryonic period, whichextends from the act of fertilisation to the end of'the eighth week; second, the foetal period, fromthe end of the eighth week to the onset of labour ;third, the intranatal period, comprising the birth_process itself.

TIE EMBRYONIC PERIOD.The embryonic (organo-genetic) period is that:

in which are laid down the sex of the offspring,its inheritance of hereditary characters, and the·general plan of all the organs of the body. Sexand inheritance are decided, according to modern.views of development, at the moment of the first-segmentation of the fertilised ovum. Malformationsof all kinds are all initiated in the embryonic period.Sex.-The mechanism by which the sex of the-

individual is determined in view of recent biologicaladvances is now clearer than it has even beenbefore; it even appears to be not impossible thatexperimental means may be found of altering the,sex ratio-that is, the proportion of males to;females--in the case of some creatures such asinsects. It is, therefore, not out of the questiomnthat not we ourselves, but those who may followus will discover some practical method ofinfluencing the segmentation of the ovum in thedirection of maleness or femaleness at will.The idea that it was possible by extraneous.

measures to determine the sex of the unborn childhas been tenaciously held since the beginning ofhistory. Gifts to pagan deities and pilgrimages to.shrines of saints represent the appeal to the super-natural which human nature is prone to make omrall critical occasions. These are, however, notstrictly speaking, therapeutic measures, and theydo not concern us now. The belief still persists.among the laity that matters can be so arranged byhusband and wife as to produce a child of thedesired sex, but this belief has no basis in accreditedfacts.

Malformations.-Let us now consider the causa-tion of malformations. We have seen that theembryonic period is the time at which those deflec-tions from the normal course of development occurwhich result in the production of malformations ofall kinds. There was no clear idea possible of thecausation of these defects until it was shown byexperiment that they could be produced by sub-jecting the developing embryo to various kindsof abnormal stimuli. From small beginnings anextensive field of experimental teratology has nowbeen covered, and it appears that there is no knownmalformation which cannot be experimentallyreproduced in the case of certain classes of animals.It is, of course, admitted that the particular stimuliwhich have been made use of experimentally couldnot well be applied to the mammalian embryo.They are all sufficiently powerful to produce actualinjury, and their effects may fairly be classed as

ANTENATAL CARE.36copyright.

on January 4, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.2.15.35 on 1 D

ecember 1926. D

ownloaded from

ANTENATAL CARE.

traumatic. These experiments lead us to believethat the cause of malformations in man must besought in some alteration of environment whichwould be comparable to the physical or mechanicalstimuli used in these experiments.

It would serve no practical purpose to enter atall fully into it, but one or two examples may be,cited of the results of injury of the segmenting*ovum. Some of the earliest experiments were madewith the incubation of hen's eggs, when it wasfound that variation in the temperature of thehatching medium in either direction resulted inthe production of a large percentage of deformed,chicks. By shaking the eggs or standing them upon end, St. Hilaire produced double-monster chicks.Other observers worked with chemical stimuli, and-it was found that the injection of alcohol into theblastomere of the incubating egg produced a largepercentage of deformed chicks.More recently experiments have been made with

the ova of sea-urchins and similar forms. It hasbeen discovered that by violently shaking the seg-menting ova in a centrifuge the component cellsbecome separated from one another and each;separate cell may then develop a complete individual-of proportionately smaller size than the normal.These experiments support the view that triplet,;quadruplet, or quintuplet pregnancy may possiblybe accounted for, not only by simultaneous fertilisa-tion of more than one ovum, but by traumaticseparation of the cells of the blastomere at a veryearly stage of its formation. With ascidian ova ithas been shown that if, in the two-cell stage, onecell is destroyed by heat, the other develops intoa half embryo. Similarly, if in the four-cell stage-the two posterior cells are destroyed the remainingones develop into an embryo minus a tail and otherhinder parts.We must not conclude that traumatism is the

invariable cause of malformations, because F. W.Browne has shown that there is good reason tobelieve that the anencephalic foetus is the result,of non-development of the pituitary body. Andfurther, remarkable effects may be produced by.alterations of nutrition. At any rate, it is clearfrom what has been said that deformities shouldnot be regarded as mere freaks of the developmentalforces, or as the result of hereditarv vicioustendencies. The future may possibly teach us thenature of the terato-genetic forces which operatein man and how to avoid them. At the momentwe have no gleam of light on the subject.

Causes of Embryonic Death.-Of the actual,causes of death in the embryonic period weknow little, and there is no reliable basis onwhich an estimate can be formed of the frequencyof embryonic death. It is probable that a con-.siderable number of miscarriages occur which arenot the result of disease, but are either producedby slight traumatic causes or are due to a certainunfitness of the early embryo to complete itsdevelopment. In all creatures the reproductiveprocess is attended by a certain amount of wastage.

The character and causes of this normal wastagehave been carefully examined by Arthur Robinsonin the case of horses and ferrets, the former beingeither Clydesdales or thoroughbreds, about whichaccurate details as to mating and foaling could beobtained. Robinson showed that in ferrets aconsiderable proportion of the zygotes or fertilisedova perished at various stages of development,although in the same uterine cornu neighbouringzygotes on either side of them developed normally.He regarded their death as being due to structuralunfitness of the zygote to fulfil its destiny and notto any abnormal maternal condition. In thisconclusion he was no doubt right. The occurrenceof foetal death in the case of mares is not clearlyproved by Robinson's data, and it would appearthat his conclusions are mainly to be read asapplicable to animals which produce their young inlitters, and in whom, consequently, a high frectaldeath-rate would not be prejudicial to the continu-ance of the species. In animals which produceonly one, or at the most two, young at birth, likemares, a high fcetal death-rate would be of graversignificance. It may be admitted, however, thatin man it is, at any rate, probable that a certainunknown proportion of the abortions which occurand for which no pathological explanation can befound may be set down to the reproductive wastagedescribed by Robinson.

THE F0ETAL PERIOD.Before proceeding to consider the conditions

which are mainly accountable for loss of fcetal life,it will be well to review one or two matters whichare concerned with what may be called the generalhygiene of the foetus in utero. Let us look at thecase of the child of healthy parents suffering fromno disease which can be transmitted to it such asthe infections, or which can prove inimical to itscontinued existence such as toxic albuminuria andeclampsia. Besides providing it with food andshelter, does a healthy mother influence the condi-tion of the child in utero by her own physical health,or by her occupation, or by the struggle forexistence ?

Transmission of Immunity.-On the thresholdof this question lies the subject of the trans-mission of immunity. Is the new-born childin any way prepared, by the transplacentalpassage of immunity bodies from the mother, toresist infection acquired after birth ? Clinicianshave frequently drawn attention to the greatsusceptibility of young infants to infections of allkinds, and the view has been often expressed thatthe child does not acquire a power of activelyresisting infection until the second year has beenpassed. Passive immunity may, however, to someextent be acquired from the mother-i.e., anti-bodies present in the mother serve to confer acertain measure of protection upon the child whileits own powers of resistance are undeveloped.It will, perhaps, be of interest to summarise as

37copyright.

on January 4, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.2.15.35 on 1 D

ecember 1926. D

ownloaded from

ANTENATAL CARE.

well as I am able the present state of our knowledgeon this subject.

For a long time it was thought that such anti-bodies as the young infant possesses reach it throughthe mammary secretion, and that mainly throughthe special secretion of the first two to three days,known as the colostrum. This view was the out-come of experimental work done on ruminantanimals such as the cow, the goat, sheep, and alsoon pigs and horses. In these animals antibodiesdo not reach the foetus in utero at all, but they arepresent in large amount in the breast milk, and canbe found in the blood of the young after suckling.Two American observers, Kuttner and Ratner, haverecently shown that these results do not hold goodfor all mammalia, and that in certain rodents anti-bodies can be detected in the umbilical blood atbirth. Similarly, these observers have shown thatantibodies can also be found at birth in the bloodof the new-born human infant. This differencebetween ruminants and rodents is attributed bythese investigators to a difference in placentation;in the former the placenta consists of a doublelayer of epithelium, while in rodents and inman the placental epithelium consists of onlya single layer, and is, therefore, more readilypermeable.The experimental work has been done mostly

with the antitoxin of diphtheria, because in thecutaneous reaction known as the Schick test wehave a very convenient means of checking theindividual power of resistance to the diphtheriatoxin.

Kuttner and Ratner found in a series of 30observations that whenever the mother gave aSchick negative test the diphtheria antitoxincould be detected in the blood of the umbilicalcord as well as in that of the mother. In a furtherseries of 15 cases in which quantitatve tests wereapplied, they found that the amount of antitoxinin the umbilical blood was identical with that inthe mother's blood. This observation has beenamply confirmed by other investigators. There is,therefore, in these animals (rodents) no loss of anti-toxin in passage through the placenta, which clearlyallows these bodies to pass through freely. Theseimmunity bodies transmitted from the mother'sblood during pregnancy would confer immunity onthe child in the same degree as it exists in themother.The observation was first made in 1895, and has

since been established beyond question by numerousobservers, that the new-born child is protectedagainst diphtheria. According to Zinsser, 93 percent. of new.born infants give a negative Schickreaction provided that the mothers are negativealso. This protection diminishes during the firstyear, so that at the beginning of the second yeartwo out of every three infants have no antitoxinin their serum. The immunity of the new-borninfant is brought about by the transplacentaldistribution of the antitoxin present in the mother'sblood, and, as we have just seen, the amount of

antitoxin is the same in both the mother's and the-child's blood.

One further observation I should like to mentionin relation to immunity. Kleinoff claims to haveshown that the umbilical blood of the new-bornchild possesses definite haemolytic or bacteriolytic-powers. He found that if the serum of the infant'sblood were added to cultures of certain bacteriathe growth of these organisms was inhibited, andin some cases the bacteria were broken up. Theeffect is the same, although less in degree than thatobtained with the blood-serum of an adult. It isclear, therefore, that the fcetus acquires certainpassive immunities in utero through the placentalinterchanges. What may be the actual extent ofthis process of passive immunisation of the childwe cannot tell in the meantime. A very wide fieldis opened up by these suggestive experiments, andalthough at present the number of infections inrespect of which it is possible to confer passiveimmunity is not large, it must be remembered thatthe science of immunology is in its infancy and greatdevelopments may be witnessed in the future.

Effect of General Maternal Conditions.-N-extwe must consider to what extent the well-beingof the foetus in utero can be influenced bygeneral maternal conditions such as nutrition,occupation, hardship, and what we may, perhaps,term "nervous stress." The tendency withinthe profession has been to consider that thefoetus, like all parasitic organisms, would succeedin looking after itself no matter how much themother might suffer from such conditions as hard-ship or under-feeding. It is doubtful if this viewcan be maintained absolutely, and there are certainfacts and considerations bearing upon the pointto which I should like to draw your attention.

If an inquiry is made as to what extent theoccupation and environment of the expectantumother may affect the well-being of the child atbirth, a serious difficulty is at once encountered:--viz., that it is very difficult to find any reliablecriteria of wel!-being in the new-born except that,of weight and length. It does not necessarily followthat the heaviest infants are the most vigorous atbirth, or that they make better progress than theothers. There are undoubtedly exceptions, but,as a rule, babies under the average weight at birthare less vigorous than those of normal or more thannormal weight. It does not necessarily follow that,every few grammes added to the weight of thechild add in corresponding degree to its vigourand to its chances of survival. It is, however, anarguable proposition that such is the case, andcertain investigations have been made upon thisassumption which are worthy of our consideration.

Effect of Maternal Occlupation on the Child.-Adolphe Pinard was for many years an advocateof the view that women engaged in industry who,continued at their work during the last three:months of pregnancy showed a marked tendency-to premature confinement; their infants were:

38copyright.

on January 4, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.2.15.35 on 1 D

ecember 1926. D

ownloaded from

ANTENATAL CARE. 39

accordingly under-sized and less vigorous thanfull-time children. He carried out an inquiry asto the weight of the child at birth in differentclasses of women, with a view to testing the effectson the child of the mother's occupation, andparticularly as to the value of cessation of work andadmission to the clinique well in advance of theconfinement. Investigations on similar lines weremade about the same time by Letourner.

This difference between the women who wereengaged in hard industrial work up to confinement,and those who had ceased work for at least a month,is represented by an average increase in the weightof the infants of the latter of 575 g. The increasein the children of the women who rested is attri-buted by Pinard solely to the fact that these womencarried their infants to term, while an undueproportion of the others did not.An independent inquiry was being carried on

about the same time in Germany and the resultswere reported by Fuchs in 1899. His work wasdone on somewhat different lines and is, perhaps,more convincing than that of Pinard. He rightlythought that in investigating the effects of maternaloccupation on the weight of the child the com-parison should be made strictly between infantsof an equal degree of development, and he accord-ingly excluded all premature infants from hisinquiry. Incidentally, it may be said that hedisagreed with Pinard's conclusion that continuancein industrial work tended to result in prematurelabour.The main conclusions which appear from Fuchs's

observations are (1) that the infants of factoryworkers are smaller than those of the other classes,(2) that the infants of all classes of patients benefitby a hospital regime during the latter weeks of preg-nancy, (3) that especially women who work infactories, and to a less extent town workers gener-ally, benefit more from the hospital regime than dowomen engaged in outdoor agricultural occupations.These conclusions serve to emphasise the generallyaccredited view that country women engaged infarm work, who are necessarily of good physique,who are engaged in outdoor occupations, and arewell-fed, are the most likely to produce vigorousand well-developed infants. The problem of theweakly infants whose chances of survival are belowthe average is essentially an urban problem.

Effect of Maternal Privation and Hardship.-Closely linked to the question of fatiguingoccupation is the question to what extent privationand hardship endured by the mother duringpregnancy can influence the well-being of the childin utero. The experience of the central Europeancountries during and immediately after the warhas shown us the result of an experiment on a scalefar exceeding that which would be possible underany ordinary circumstances. The reports fromGermany and Austria were almost unanimous thatno appreciable diminution could be detected in theaverage weight or length of infants born duringthese years of privation. One authority, Prof.

Klotz, of Liibeck, has, however, noted a pointwhich is worthy of consideration. In the years1919 and 1920, which were, perhaps, even moredifficult for the lower classes in Germany than theactual war period, Klotz found that if a comparisonwere made between the legitimate and illegitimateinfants it was found that while the former showed nodifference in weight between pre-war years and thesetwo post-war years, itwas not so with the illegitimateinfants.

It is to be borne in mind that for a long timebefore the war the proportion of illegitimate birthsin Germany was unusually high-viz., between9 and 10 per cent. of the total births. This alreadyhigh proportion increased during the war periodbecause the number of legitimate births becamereduced at a much greater rate than the illegitimateones. The stress of hardship and want will naturallyfall more heavily on the illegitimate mothers thanon others, and it is not unreasonable to supposefrom these data that there is a limit beyond whichsuch conditions as privation and hardship wouldbecome definitely detrimental to the child inutero.While we are speaking of the effects of war con-

ditions I should like to call attention to a furtherpoint-viz., their influence upon the occurrence ofstill-births. The accompanying chart shows the

Rait

49 0o ,qA 'jqj 191q4 /A.. /AFI /9/l ,/9,1 /9/9 /9*o1/9??#8

0

47.5#7 0

4r6 546-o.

AifS0

,,~.oI I

4#*oJ

46.0

changes which occurred in the stillbirth-rate inFrance during the period covered by the war andthe two following years. The figures are workedout in their ratio to the total births, and it willbe seen that a marked rise in the stillbirth-rateoccurred during the years 1916-19. The corre-sponding figures for our own country are notavailable. War conditions included so manydifferent varieties of privation and nervous stressthat it is impossible to attempt any explanation oftheir modus operandi. We must simply record thefact that there is a point beyond which such con-ditions are unfavourable to the proper developmentof the fcetus. (To be concluded.)

The second Duveen lecture in Otology--it isopen to medical practitioners-will be given at theUniversity College Medical School by Mr. RICHARDLAKE, F.R.C.S., at 5 P.M. on Tuesday, Dec. 7th.His subject, which will have a special appeal tomany of our readers, is otitic intracranial abscess.

copyright. on January 4, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.2.15.35 on 1 Decem

ber 1926. Dow

nloaded from