► The Tiniest Humans
by Robert Sassone
Released October 5, 2005

Second edition
by Robert L. Sassone
based on interviews with

Professor Jerome Lejeune
and
Professor Sir Albert William Liley

Foreword

The discoveries of Doctors Liley and Lejeune were among the greatest ever made.

Dr. Liley discovered that preborn humans could be treated like any other patients, and did the pioneer work in developing the techniques of observing and treating preborn humans, techniques that are used today. For this he was knighted, and other doctors gave him the title "Father of Modern Fetology," fetology being the study of the fetus or preborn human.

Dr. Lejeune discovered the cause of Down's syndrome, and discovered that humans might have more than 46 chromosomes. Some regarded him as the leading geneticist in the world. Both of these men were given the highest honors by many nations.

Liley and Lejeune came from opposite ends of the world to testify at the U.S. Senate hearings on abortion. They also testified and were questioned by a New Zealand Royal Commission on abortion. They gave numerous talks, and wrote many articles for medical publications. This is the first book to which they contributed for the general public.

Albert William Liley: 1929-1983
Professor Albert William Liley died in Auckland, New Zealand, in 1983 but his great work for the preborn lives on. His tragic death at the age of 54 robbed the medical world of the keenest mind his country has produced. He was Professor of Perinatal Physiology in the Postgraduate School of Obstetrics and Gynecology at the University of Auckland. He had over 40 scientific papers published on a wide range of subjects and was internationally acclaimed.

His education began in his home town of Auckland. He was awarded a B.S. in Medical Science in 1953 and graduated from Otago Medical School in 1954. As a student he was a gold medalist in anatomy (1950), held a senior scholarship in medicine and was awarded the traveling scholarship in medicine (1954), which he declined. While in medical school he distinguished himself as a member of the fencing team.

Prof. Liley was a brilliant student at school and at university, but he was merely an obscure professor until his ingenious achievement of intrauterine blood transfusion for Rh-affected babies, which revolutionized the management of this condition and dramatically improved the prognosis for these children. For the first time the baby came to be seen as a patient who could be diagnosed and treated. By a happy coincidence the British Medical Journal article announcing his great discovery appeared on the day that Queen Elizabeth was visiting his hospital-National Women's Hospital in Auckland.

After this Liley received innumerable invitations to address scientific meetings in the United States, England, Europe, Australia and many other countries. Among the many honors showered on him were his knighthood, KCMG (Knight Commander of St. Michael and St. George); an Honorary Fellowship of the American College of Obstetricians and Gynecologists; a similar Fellowship of the Royal College of Obstetricians and Gynecologists; a Ph.D.; a D. Sc.; and several others. One honor that he valued more than most was being elected a (non-Catholic) member of the Pontifical Academy of Science in Rome.

Prof. Liley was tremendously disturbed by the liberal legislative stance that was being established toward induced abortion. "Because of the facts uncovered by my research," he said, "as a doctor I have no alternative but to regard the unborn child as my patient, and to respect his life as I would the life of any other patient. From my clinical experience, I am convinced that unborn children are individuals and human beings who should have legal protection, and who are capable of receiving and responding to medical care." How wise and prescient was the good doctor. Today the preborn patient is not only treated medically for cardiac and other problems, he or she can be partially removed from the womb, receive surgical repair of a diaphragmatic hernia, and then be returned to the uterus and allowed to grow normally to term.

With great humor Prof. Liley described the identity problems experienced by our preborn brother and sisters in the pre-sonogram days. For one thing, he noted that the fetus's seclusion and inaccessibility for study led to many different theories regarding abilities. "As examples," said Prof. Liley, "at one extreme we could have Jean Jacques Rousseau and his pupils considering that the mind of the newborn baby was a tabula rasa, a clean washed slate. In other words, the baby had not had any sensory experience before birth. At the other extreme we could have Sigmund Freud and his pupils describing episodes recalled from dreams of the fetus spying on his parents having intercourse during pregnancy. You know, what the butler saw through the cervix."

In his home country he became the Founder-President of the Society for the Protection of the Unborn Child, a gesture that took considerable courage because it placed him in opposition to most of his colleagues in obstetrics and gynecology. But he had a nobility of character that would not let him accept the injustice of induced abortion, or the way the medical profession was abandoning its Hippocratic traditions in the face of the intimidating sexual revolution.

Prof. Liley was most distressed that his development of amniocentesis to help the preborn patient was being stood on its head. His peers were using this same technology to identify babies in the womb who were suffering from an incurable disease, i.e., Down's syndrome, and recommending that they be killed before birth because of an anticipated "poor quality of life." We shall not see his like again. May he rest in peace.

Professor Jerome Lejeune: June 13, 1926-April 3, 1994
(Adapted from UFL Pro Vita, Volume IV, Number 3, May 1994)

Jerome Lejeune died of cancer in Paris on Easter Sunday morning at the age of 67. He was an internationally renowned geneticist who became famous in 1959 when he identified the extra chromosome that often results in mental retardation and various physical problems for people with Down's syndrome. He spent most of the rest of his life seeking a cure.

The right-to-life movement has lost a mighty warrior. No blazing fire or sounding trumpets accompanied him into battle. He approached the fray with a gentleness and humility that were consuming. His greatest weapon was an intellectual acuity that delivered the truth with telling force. His Christ-like demeanor in no way hampered his effectiveness.

Dr. Lejeune was born in Montrouge (Seine) in France and was the father of five children. In 1963 he became Director of the Center National de la Recherche Scientifique. He was appointed a University Professor of the former University of Paris in 1964. In 1974 he became a member of the Pontifical Academy of Science. At the time of his death he was Professor of Fundamental Genetics at the Universite Ren? Descartes in Paris. He received many scientific and humanitarian awards.

When American pro-lifers needed testimony for congressional committees, Dr. Lejeune was there. When they needed an expert witness in the court case concerning frozen embryos in Tennessee, he again responded (his testimony is found in his book The Concentration Can, Ignatius Press, 1991). When they needed a witness in the Loce case in New Jersey or the clinic access case in Kansas, he was there. In two separate cases two judges ruled that human life begins at conception.

One of his greatest gifts was the ability to communicate very complex truths in a fashion understandable to all in his audience. His presentation of the data on the beginning of human life was truly memorable. He taught us that the chromosomes are the table of the law of life, and when they have been gathered in a human being they fully spell out his or her personal constitution. This constitution is donated to every human person by his or her parents and is transmitted by the molecular thread of DNA. Lejeune captivated his audiences when describing the minuteness of this genetic information. He stated that if all of this information could be collected from the five billion or so persons now inhabiting the earth, it would approximate the size of two five-grain aspirin tablets. He stressed that each one of us is unique from the moment of conception and that this uniqueness can today be demonstrated scientifically.

Highly acclaimed by the world's scientific community, Professor Lejeune was a member of the American Academy of Arts and Sciences, of the Royal Society of Medicine (London), and the Pontifical Academy of Sciences (Rome) and holds honorary doctorates from the Universities of Dusseldorf and Pamplona. He won the international Kennedy award, which is given every three years for work in the field of mental retardation. The award winner is selected by an international board of scientists. In 1970, he received the international William Allen Memorial Medal from the American Society of Human Genetics. In 1966, he received a special distinction for scientific writers involved in biology from the Union of Soviet Socialist Republics. In 1962, he received from the Academy of Science in Paris their prize for work in biology.

The magnitude of Prof. Lejeune's contribution to our cause cannot be measured. He will be sorely missed. Please pray for the repose of his soul.

Development of the Tiniest Humans
An interview with Sir Albert William Liley

Liley: I am a registered medical practitioner. I had the appointment of Professor of Perinatal Physiology in the Postgraduate School of Obstetrics and Gynaecology, University of Auckland, and I am a member of the consultant staff of National Women's Hospital, Auckland, New Zealand.

For the past nineteen years, my main field of research and clinical practice has been the care of unborn children. Initially this work established accurate diagnostic tests by which the condition of the unborn Rh baby could be assessed. In 1963, I developed a technique for the transfusion of blood to the baby in utero. This work demonstrated conclusively that the unborn child, like any other person, could be ill, and could have his disease diagnosed, his condition assessed, and his malady successfully treated. The diagnosis and therapy of each of these babies before birth is as precise and specific as the continuing care and attention they receive after birth.

Although this early work was concerned primarily with the problems of the Rh baby before birth, the experience gained, and the techniques developed, are now being exploited for the diagnosis and management of an ever-widening range of disorders in unborn children. This situation highlights the fact that, in modern antenatal care, we are concerned with the welfare of two patients: the mother and the child.

In a number of genetic and biochemical problems, definite diagnosis can be established as early as the 14th week and, in the Rh baby, therapy has been undertaken as early as the 18th week of intrauterine life. With advances in technology these limits are being moved back earlier in pregnancy. The division of intra-uterine life into segments (zygote, fetus, etc.) is a semantic phenomenon, and is in no way supported by biological or medical fact. We are caring for the same child throughout pregnancy, before as well as after birth.

Because of the facts uncovered by my research, as a doctor I have no alternative but to regard the unborn child as my patient, and to protect and respect his life as I would the life of any other patient. From my clinical experience, I am convinced that unborn children are individuals and human beings, who should have legal protection and who are capable of receiving and responding to medical care.

In my opinion, therefore, abortion is abhorrent, and represents a policy which would be regarded as immoral and criminal with a patient in any other age group.

For that reason I have been disturbed by developments in favor of liberal abortion policies. The arguments, as I understand them, seem to concentrate on the wishes of the mother rather than an accurate and factual evaluation of what is involved in an abortion. In particular it seems to me that the facts relating to the unborn child are being distorted (whether deliberately or through ignorance, I do not know) so as to give the public the impression that the fetus, particularly in the first twelve weeks, could hardly be treated as a "child." It appears to me that the public could be vulnerable to propaganda of this kind.

As any high school biology textbook will tell us, life begins at conception and ends at death. In between, life does not develop; it is simply there.

What does develop is the morphological structure, the earthly home of life, the physiological performance of that structure, behavioral traits and personality. And, as we increasingly expand into a community of like individuals, we can speak of development of social responsibilities, of ethical awareness and legal status.

Unfortunately, this expansion of concept is accompanied by a deterioration in fact and specificity. Any modern textbook of embryology will accurately recount the earliest stages of morphogenesis of the human body. A little behind but catching up are accounts of the physiological performance and behavior of the embryo and fetus.

In other words, when dealing with observation and sensory data there is good agreement. But, as we expand into social, ethical, legal and political fields, hypothesis and conjecture become more evident.

For many centuries, the only serious students of fetal life were those who delivered babies, and the embryologist. The former were concerned with mechanical problems as babies presented in delivery. They were concerned with facts such as which way around the baby was or how big it was and the relationship of the diameters of a specific part of the baby to the diameters of the birth canal. In proof of this contention, one need only remember that the great and famous in obstetrics were those whom we might call the "square peg in the round hole" men. These people designed and worked out better ways to design and use forceps, better ways to deliver breech births, how to do Cesarean sections, and how to get the placenta out. While nobody would deny the tremendous contributions to human welfare made by the mechanical obstetricians, it is easy to understand how they left the development of and function of fetal life untouched until recently.

Embryologists for their part studied dead static tissues, and attempted to deduce structure from function or function from structure. This is not an easy task. I can tell you that there are still physicians practicing who can remember being told as medical students that the pituitary gland was a vestigial structure with no known function. In other words, who, while looking at a slide of the pituitary gland, in their wildest moments could have dreamed of just what this structure does? As a result, it is not surprising that, for many centuries so long as these were the only serious students of the fetus, the view should grow up that the fetal life was a time of quiescence, of blind development of structures and anticipation of a life and function that began at birth.

The seclusion of the fetus in the uterus and its unavailability for study for a long time had two further rather unfortunate effects. The first of these was that much reliance was placed on animal work despite the fact that the physiology of gestation varies more throughout the mammalian order than the physiology of any other body function. Much reliance was placed on those studies of animals-which studies were quite invalid when applied to human pregnancy.

Second, for want of the knowledge with which to make serious challenges or repudiation, many theories flourished. You might not be able to prove yourself right, but at least nobody else could prove you wrong. As examples, at one extreme we could have Jean Jacques Rousseau and his pupils considering that the mind of the newborn baby was a tabula rasa, a clean washed slate. In other words, the baby had not had any sensory experience before birth. At the other extreme we could have Sigmund Freud and his pupils describing episodes recalled from dreams of the fetus spying on his parents having intercourse during pregnancy. You know, what the butler saw through the cervix. So you see, you could entertain any theory you like, one extreme where the fetus was a witless tadpole and at the other extreme where the fetus was a skilled voyeur. If you could not prove yourself right, at least nobody else could prove you wrong. Now, by contrast, because we now have both the opportunity and the technology to invade the privacy of the fetus, we can replace all this fascinating conjecture with facts, which I hope are more interesting.

The first myth we will explore is that the fetus spends pregnancy swallowed up in the uterus as if it were quite confined in a cramped cabin. In point of fact, the fetus has plenty of room for the first two-thirds of pregnancy. During the first two-thirds of pregnancy, the fetus is under no restriction or restraint and is not obliged to lie well-fixed. It is very easy to demonstrate now with ultrasound that the babies make the most of all the space and room available to them in the early stages of pregnancy and move around and turn over and over like yoyos. We can see the tiny forms of babies scooting around in the uterus. We knew they did this long before because by fetal electrocardiography one can detect from the direction of the major deflection the orientation of the baby. Since the main cardiac dipole in the fetus is very strongly in the long axis of the fetus, we can get a record with two sets of mutually orthogonal (perpendicular) leads on the mother's abdomen, one longitudinal and one transverse.

You can first see neatly ringed on the bottom trace the deflections of the fetus, but at that time you may not see any on the top trace because he happens to be transverse. When the deflections disappear on the bottom trace, they appear on the top one and then they disappear off that one and reappear on the bottom one again. You can detect the baby doing complete flips, which take about two-and-a-half seconds.

When we say that in early pregnancy the babies roll over and over like yoyos, this is not an exaggeration. These conditions of movement still prevail as late as 28 weeks. After it gets too crowded for the wilder gyrations, we can still see the baby flex and bend his limbs as he pleases. In fact, it is only in very late pregnancy that the baby starts to become short of room.

It is very clear to us that it is a purposeful quest for fetal comfort that determines fetal position. Our interest in this field and this conclusion has been forced on us by our interest in fetal therapy. If you are going to carry out procedures like fetal transfusion, you want the baby lying in a suitable position for it and it helps to know why the babies lie the way they do. It is obvious babies lie the way they do in any given instant for very good personal reasons which are those of fetal comfort.

Conditions prevailing in late pregnancy are rather altered because we no longer have a relatively small baby in a relatively large englobular cavity. We now have an ovoid cavity with its lower pole or end narrower. We have a baby who has grown enormously compared to the uterus. The relative volume of amniotic fluid has diminished. It might seem that since the baby has grown a lot bigger and the baby's head is his biggest part, he should put his head in the big end of the uterus. In fact he does not do that because the baby is now much longer than the uterus. He must fold to fit in. His most common attitude at this time is one of flexion. It so happens that the fetal head forms a smaller pole than the combination of his back, his thighs, his calves and his feet. What the baby does normally is to lie with his long axis in the long axis of the cavity, his little end (which is his head) in the little end of the cavity, and his big end (which is a combination of his back, his thighs, his calves and his feet) in the big end. As far as we can see, this is the reason the great majority of babies lie in this position in late pregnancy, simply because they fit in best that way. Photos show that babies with ingenuity find many alternative solutions to this problem of comfort. If the baby elects to extend his legs rather than flex them, then he will fit in best as an extended leg breech, because his neatly tapering back and thighs form a smaller pole than his head. The baby is still playing the game according to the same set of rules. His long axis in the long axis of the cavity, his little end in the little end of the uterus, the big end in the big end. This is an alternate position of fetal comfort in late pregnancy. About 4% of babies elect to lie in it.

All sorts of things can disturb this relationship between the mother and the little baby in the uterus. If the uterus is subaccurate, this relatively common and trivial abnormality of the uterine contour can have relatively startling effects on fetal presentation. No longer is the long axis of this cavity longitudinal, but oblique. The baby obediently lies in the new long axis, the oblique one. He still plays the game according to the rules, the little end at the little end and the big end at the big end.

Severe Rh disease associated with the large placenta and an unusually sited placenta has the same effect as the uterine malformation. It gives you a long axis of the cavity which is oblique, not longitudinal. The baby lies in that long axis, the big end in the big end, and the little end in the little end. It's a very simple game.

Babies do not lie in these odd positions to make life difficult for the obstetrician or dangerous for themselves or their mothers. They lie in these positions in late pregnancy because of the purposeful quest for fetal comfort. It is the most comfortable position they can find. In selecting a position of comfort in late pregnancy, a baby may have chosen a position which is hazardous or difficult or impossible for a vaginal delivery and in which regard the fetus can be accused of a lack of foresight. This, of course, is a trait not unknown in adults.

Those babies who lie as extended leg breeches were lying in those positions because that was the best way they fit in. There is an alternate solution used by some babies, and that is to lie as an extended vertex and again a small minority of babies do this. We have a large quantity of photos of such presentations. This is a matter of individual fetal choice.

Anyone who has ever had the experience of trying to get comfortable two to a single bed will appreciate the difficulties twin children have. Many mothers who give birth to twins have been surprised to find that there were only two babies. From the amount of kicking they were getting, they would have thought they were going to have half a dozen. We suspect they may in fact be quite correct. We have work underway currently in which we are measuring the amount of fetal activity or movement by several techniques. I think that we may well find mothers of twins are quite right and that two babies do move more than twice as much as one. The reason for this would be that not only does each baby have to be comfortable in relation to his mother, but in relation to his twin as well. If someone moves over in bed, that means that everyone is going to have to move over. Another interesting thing to note is how reluctant twins are to lie with their heads in the same pole or direction of the uterus. This is easy to understand. If they lie in the same direction, they may bang their heads together during their movement or movement by the mother, so normally they lie with their heads in opposite directions. In other words, they lie head and tail.

We have photos that measure the quantity of fetal activity. We photograph the trace of an ultrasonic beam deflected off fetal limbs, which trace tends to reliably reflect the velocity of the fetal movement. We utilize a ballistic technique by which we subtract internal respiratory excursion in maternal ballisto cardiogram and we're left with a record of larger fetal movements.

Our generation is the first ever to have a reasonably complete picture of the development of the human from conception. In 1930, the liberation of a human egg from the ovary was first observed. In 1944, through a microscope, was seen the union of the human sperm and ovum. In the 1950's, the events of the first six days of life were described, those critical first steps in a prodigious journey.

In recent years, three further advances occurred. First, as I have said, the direct diagnosis and treatment in a baby before birth became a reality. Second, the physical environment and physiological behavior of the fetus became accessible to study. Thirdly, the genetic code was cracked, the alphabet established in which is spelled out the instructions which guarantee that every human is unique and different from every human that ever was or ever will be.

These 40 years of discovery put an end to centuries of guesswork and controversy, of ideas of generation, animation, ensoulment and encapsulation. For a generation that reputedly prefers scientific fact to barren philosophy, we might have thought that this new information would engender a new respect for the welfare and appreciation of the importance of intra-uterine life.

Instead, around the world we find a systematic campaign clamoring for the destruction of the embryo and fetus as a cure- all for every social and personal problem. I for one find it a bitter irony that just when the embryo and fetus finally arrives on the medical scene there should be such sustained pressure to make him or her a social nonentity.

In this Orwellian situation, where so much semantic effort and logical gymnastics are expended in making a developing human into an "unperson," modern anatomical, genetic, immunological, endocrinological and physiological facts are a persistent embarrassment.

How much easier to echo that simple statement "But there's nothing there yet," without pausing to reflect that if there is nothing there, then why the unholy rush to remove it? Nevertheless, not everyone is away with the fairies, and for the benefit of those still in touch with reality we can briefly review some aspects of intrauterine life.

Q:What features show that the baby has an independent existence in the uterus?

A: First, that he is entirely responsible, not only for his own development, but also for the organization of pregnancy. He has influences, while still no bigger than a grain of sugar, on the mother whose body weight is measured in kilograms. While this is by no means novel in biochemical or physiological circumstances, as I have said, it is an astounding feat of power ampli-fication and demonstrates the importance of his own survival to the baby so that he does in fact take over in the human the direct control of the pregnancy.

Q: So this little person no bigger than a grain of sugar starts off what you might call a cascade reaction?

A: Exactly, by his own performance. Next he organizes, or solves rather, the homograft problem. I think most people would be familiar with the fact that no matter how much you needed somebody else's kidney or heart, and no matter how willing he was to let you have one because he had one spare or no longer needed his, you simply cannot go around indiscriminately accepting spare part organs from other people, and yet we have this fascinating situation by which a baby and his mother, who are immunological foreigners, have to tolerate each other's tissues in parabiosis, and it may be a source of some satisfaction that a solution of the homograft problem, which so far has defeated the best brains in surgery and immunology, was in fact personally solved by you and me before we were born, or we would not be here today. A Nobel prize awaits the man who remembers how he did it.

We each began life as a single cell. 45 generations of doubling of number of cells by growth divisions were needed to reach the 30 trillion cells of an adult. Of these 45 generations of division, eight, or nearly one-fifth, have occurred by the time we were eight weeks old, 39 by 28 weeks' gestation, and 41 by the time we were born. The remaining tedious four occupied the whole of childhood and adolescence, and then there were no more.

Q: Could you describe those later cell divisions briefly?

A: It is very simple. One can also distinguish several kinds of cell division. There are those that are replacing cells that have been lost or damaged. These are replacement divisions. One can distinguish, also, growth divisions in which one cell divides into two, each of those divides into four, and each of those steps in the division is a generation, as it were, of cell division. This is very like the problem of the grains of wheat on the chessboard: one on the first square, two on the second square, four on the third, eight on the fourth, and so on. It is simply a geometric progression. And if one asks how many generations of cell growth division are needed to get from that single cell to the 30 trillion cells of an adult, then the answer is about 45 generations of cell division. And of these, 41, say, have occurred by the time we are born. Therefore, you see, as we spend about nine months, or three-quarters of a year, in the uterus, and our three score years and ten are something like three-quarters of a century, out of it, it could be easy to think of that intrauterine life as occupying about one percent of our growth and development, 41 of those 45 generations of cell divisions have occurred before we were born. In other words, the sort of person we are going to be in terms of our physical growth, our physiological attributes, and our function-90 percent of the excitement is over by the time we are born. 41 of the 45 cell divisions have occurred. It is for this reason that we regard the care of pregnant women, and this stage of life, as so important, as rapidly growing cells are particularly vulnerable to inimical influences, and if anything does go wrong this can cast its shadow so far into the future.

Q: And when do the remaining cell divisions happen that occur after birth?

A: They occur up to adolescence but, in the uterus as out of it, and out of it as in it, growth tends to be a steps-and-stairs phenomenon. We are familiar with the growth of the child in adolescence; this is not evenly spaced either.

Q: So this is really part of a continuum that started off from the word "go"?

A: Exactly.

This dramatic and rapid sequence of cell replications in early intrauterine life is matched by an equally dramatic and rapid differentiation and morphogenesis. After a six- to eight-day journey down the Fallopian tube, our new human reaches the uterus, his home for the next 270 days, and burrows into the spongy lining. He promptly develops a placenta and a protective capsule of fluid for himself.

Q: You get no changes in the endometrium before implantation to suggest that fertilization has taken place?

A: One could imagine so just before implantation occurred, but these are not of useful or practical sense or purpose. In other words, the hormones excreted by the conceptus very soon after implantation have produced a rapid and occasionally capriciously unreliable test for early pregnancy.

Q: What about the decidual changes in the endometrium? When do they become recognizable?

A: Within a very short interval of implantation, but this is not primarily a uterine change at all in that it can occur in other places where implantation occurs, for instance in the Fallopian tubes.

Q: But it does indicate implantation?

A: Yes.

Q: Do I correctly assume there that you are asserting as a fact that implantation takes place at the end of the eighth day or the ninth day?

A: No, it appears more variable than that, both in time and in place, but at the end of a certain interval, about five to nine days-commonly about six to eight-the conceptus will implant wherever it happens to be, whether in the uterus or not, and in some instances there is a tubal pregnancy.

Q: We have had evidence that the time stretches to 11 days?

A: True.

Q: Is it possible to pinpoint this?

A: No, it is quite variable. As a matter of fact, whether a baby ends up implanting or whether or not he implants at all depends on two factors-where he is, and when at a particular stage of development he sheds a capsule that is normally like a plastic backing on a lipstick label. In other words, there is a stage during the journey of the zygote at which it is non-tacky, and eventually this capsule surrounding it disintegrates, and at that stage it is very tacky and sticks on wherever it happens to be, and that is the reason why some stick in odd places. There may be mechanical delays in this journey due to abnormalities of the mother's tubes, or there may be abnormalities that hurry this. There may also be variations in when the capsule actually disintegrates.

By 25 days from conception, the developing heart starts beating, although two or three weeks must elapse before we can reliably detect heartbeats with current technology. These first strokes of the pump are not associated with a circulation, but with an ebb-and-flow system as envisaged by pre-Harveyian physiologists, for the cardiovascular system is initially valveless. But soon valves develop and, with a pump to provide a pressure gradient and valves to give direction, we have a circulation.

By 30 days, just two weeks past mother's first missed period, the baby-one quarter of an inch long-has a brain of unmistakable human proportions, eyes, ears, mouth, kidneys, liver, an umbilical cord and a heart pumping blood which he himself has made.

By 45 days, about the time of the mother's second missed period, the baby's skeleton is complete-in cartilage, not bone, at first; the buds of the milk teeth appear and he makes the first movements of his body and new-grown limbs, although it will be another 12 weeks before his movements are strong enough to be transmitted through the insensitive uterus to be detected by mother's sensitive abdominal wall. By 63 days he will grasp an object stroking his palm and can make a fist.

Q: Could the EEG reading of a 50-day fetus resemble that of an adult under any of a number of anesthetic agents, but not that of a normal unanesthetized adult?

A: The EEG of a 50-day fetus does resemble that of an adult under any of a number of anesthetic agents, but not that of a normal unanesthetized adult.

These structural changes, of course, are not mediated by any external agency, but internally, directed by the baby, who is called the zygote or embryo. In this regard the baby or zygote with his cargo of genetic information is much more than a mere blueprint of a new human. A blueprint is simply a plan, and does not include the machinery to fulfill that plan-but a zygote does. He even has the power to phenocopy himself, to reproduce asexually as about one in 400 zygotes or embryos does in identical twinning-and there is no known external agency that affects the incidence of identical twins.

However, our new human has in hand even greater designs and undertakings than simply his own internal organization and development. He also develops his own life-support system, his placenta, and his own confines, for it is the embryo and fetus who develops his membranes, forms his amniotic fluid and regulates its composition and volume. Women speak of their waters breaking and their membranes rupturing, but such expressions are so much nonsense-these structures belong to the baby. This simple point is not a play on words, but a practical reality. Tests on the amniotic fluid are tests on the baby, not on the mother.

But even the organization of his own confines does not exhaust the list of achievements of the new individual. His own welfare is too important to permit leaving anything to the chance cooperation of others, and therefore he must organize his mother to make her body a suitable home.

First, and most pressing, he must prevent the menstrual shedding of the endometrium. He does this by producing chorionic gonadotrophin to prolong the normally strictly limited life span of the corpus luteum, which in turn maintains the endometrium to undergo a decidual transformation.

This is a splendid feat of power amplification, understandable in electronic circuitry and very common in physiology, whereby an embryo barely out of the microgram range influences the corpus luteum in the milligram range, which in turn affects the endometrium measured in grams. Very soon the embryo bypasses the corpus luteum and takes over direct control of the endometrium- from a very early stage of human pregnancy neither the maternal pituitary nor ovaries are necessary for its continued endocrine success.

In this regard the explanations in a dozen textbooks of witch's milk, of sebaceous retention cysts, of labial hypertrophy and withdrawal bleeding in the baby girl as the result of fetal exposure to high levels of maternal sex hormones are quite wrong. It is the mother who is exposed to high levels of fetal hormones, for these hormones are manufactured by the fetus and his own placenta. These hormones are influential beyond the mother's pelvis, for they modify maternal cardiovascular, respiratory and renal function to cope with fetal requirements.

Another crucial environmental problem which must be dealt with is the homograft situation-the fact that the fetus and his mother, inevitably immunological foreigners, who could not exchange skin grafts and could not be safely given a blood transfusion one from the other, yet must tolerate each other's tissues in parabiosis for nine months of pregnancy. Again it is the fetus, not the mother, who copes with the problems. And finally it is the fetus, not the mother, who determines the duration of pregnancy, for unquestionably the onset of labor is normally a unilateral decision by the baby.

Q: I wonder if I could put a proposition to you, and if you would comment on it, please. Can we say that the maturation of fetal hormones has an effect on the mother that determines the time of birth-an effect that is biochemical and involuntary?

A: This would be a reasonable proposition in terms of the duration of the pregnancy in weeks and days. On the other hand, in terms of the diurnal variation in onset of labor, this could be affected by external environment rather than being an internally programmed event. Thus the duration of the pregnancy is clearly not something blindly imprinted on a baby's genetic endowment at conception, because obviously it can be influenced by a number of factors such as fetal illness, and so on. In other words, it is an externally negotiable phenomenon. It is not a predetermined, blindly programmed event.

Q: So you are not intending to impute will or deliberation to the fetus?

A: No, nor in similar circumstances would I impute will or deliberation to an adult.

Q: Is the choice of birth date by the baby a rational decision?

A: No, it is not a conscious or rational decision. Obviously some babies, if we wish to continue in the idiom, are radically mistaken about when they should be born. We are sure we know much better, but the great majority are not mistaken. The point is that there is evidence that the duration of pregnancy is genetically determined. For instance, in different breeds of sheep, whether it is 147 or 152 days, there does appear to be a genetic component. There is no question also that in the case of the human fetus this is modifiable by a number of agencies, including external environmental agencies-for instance, a virus infection-and a number of infections that can lead to premature labor. But nevertheless it is the fetus who is physiologically responsible for the triggering of labor.

Q: What is the mechanism whereby the fetus triggers the onset of labor?

A: There are several gaps in the human story, as I understand it. The process is much better worked out in sheep. There are obviously very similar steps in the human, but some of them are very decidedly different although some of them are the same.

Q: I wondered about medical induction to bring on a woman's labor. What is involved in the process of a medical induction?

A: Traditionally the term "medical induction" was applied to the giving to a woman of what is known as the OBE. It is not one of her Majesty's birthday honors; it stood for oil, bath, and enema, and whereas one can understand the cleanliness I wonder what the oil had to do with it, although castor oil seemed to have the reputation of stimulating intrauterine action. However, with the benefit of hindsight, I have the uneasy feeling that if you give a woman pains in the stomach they must be labor pains, and I have some doubts about this. Fortunately we now have much more specific techniques. Medical inductions in this sense now imply the use of oxytocin-or Syntosin, which is the trade or brand name. Oxytocin is a substance produced by the posterior part of the pituitary gland. However, although oxytocin can produce an excellent clinical imitation of labor, there are serious doubts that it has anything to do with normal labor. The other agent is a material, prostaglandins, which we think is much nearer and is actually involved in the process by which the fetus does initiate labor. It is one of the steps in the pathway.

Q: Do the prostaglandins and oxytocin have the effect of causing contractions in the wall of the uterus, so as to eject the child?

A: Yes.

Q: Does it follow that the triggering off of the birth of a child which proceeds, say, to full term involve some process whereby the pituitary gland gets a signal which causes it to release prostaglandins or something of that kind which sets up a contraction in the uterine wall and ejects the child?

A: Yes, provided you put enough steps in the pathway, and so on-and it is a long and involved pathway.

Q: In relation to medical or surgical induction, Professor, in effect does the baby eventually take over still and promote the process of labor?

A: In the great majority of instances, yes, provided one is in reasonable proximity to term. It is easy to, as it were, activate the triggers in the baby. There are some other instances, though, in which we appear to be producing the whole labor out of the bottle.

This relationship between a baby and his mother is clearly much more than simple biological parasitism. The term "parasite," so frequently used to describe the fetus, is often used, not in the limited biological sense, but with the sociological overtone of describing someone who takes all and contributes nothing. Neither sense is applicable to the fetus. True, he is parasitic on his mother for his nutritional requirements. In the same sense wives could be said to be parasitic on their husbands' incomes; but just as wives would indignantly maintain that they contribute much to a home and a marriage to justify their keep, and that really what is involved is a division of labor, so also does the fetus justify his keep by organizing and maintaining the pregnancy. Such a relationship is more accurately described as parabiosis or symbiosis, and physiologically there is no question who guarantees its success.

Q: It has been suggested that the baby in effect acts as a parasite on the mother and will take what it wants whether or not the mother is suffering from, say, malnutrition or otherwise. Is that a correct statement or not?

A: In general terms it is parasitic on its mother for nutrition, although some of the evidence used in the past in support of this-the fact that malnutrition seems to make very little difference to the birth weights of babies suggests that no matter how badly off the mother was the baby cruelly took all it needed to the mother's detriment. The other evidence in support of this was the relatively minor depression of birth weight which occurred in western Holland in 1944, where there was widespread protein-calorie malnutrition. However, what was overlooked in this data was the fact that the birth rate in Holland crashed. There was a very high incidence of malnutrition, women stopped menstruating and ovulating, and only the exceptionally favored were fertile, let alone would willingly undertake pregnancy-there was no point in having babies, anyway. But the fact that there was protein and calorie malnutrition, and the fact that the birth weight was not much affected-the two did not go together.

Q: So it would be fair to say in some ways it is parasitic, but you have to view the evidence that supports this with a degree of reservation?

A: Yes.

This concept, that the fetus is in command of the pregnancy, is hardly news to any mother with an unplanned pregnancy, but the idea is new and the consequences are far-reaching in obstetrics. No longer can we understand the physiology of pregnancy if we remain in ignorance of the physiology of the dominant partner in that relationship. All the problems in pregnancy which can be solved by pulling and pushing and cutting have been solved-the only unsolved problems, spontaneous miscarriage, premature labor, toxemia and so on, await a better understanding of fetal physiology.

Q: When you say, "A better understanding of fetal physiology," it seems that the problems you see relate to the fetus?

A: Some of these problems are quite serious for the mother as well-toxemia, for instance.

Q: But the unsolved problems so far as the mother is concerned are physical rather than psychological?

A: Far from it. All I would say is that in the jigsaw puzzle of knowledge we have far more pieces of the puzzle of the mother's problems than of the fetal physiology.

These achievements of the fetus also cause us to reconsider another point-the concept of maturity. It is perhaps one of the misfortunes of medicine that we study our subject as young adults, and our standards of normality are those of the young adult-usually male. And it is a part of the arrogance of young adults to consider that the only people who matter are young adults. Since maturity equals adulthood, the fetus is, by definition, immature, but immaturity acquires a nasty overtone suggesting inferiority. Thus the tendency has developed to consider the fetus, or neonate, as a poorly functioning adult rather than as a splendidly functioning baby. Every age and stage of life has its excellencies and its weaknesses, and fetal life is no exception. We do not regard the fetal circulatory system, different as it is from the child's or adult's, as one big heap of congenital defects, but rather a system superbly adapted to the circumstances under which a fetus lives.

We should not regard fetal and neonatal renal function, asymmetric as it is by adult standards (he handles a water load well but not a solute load unless he has plenty of water), as inferior, but entirely appropriate to the osmometric conditions in which it has to work.

We should appreciate that the fetus has a much more prompt and reliable response to hemorrhage than adults; that a fracture which would incapacitate an adult for three to six months will heal in three weeks in a bandage in a baby; that the ability of a fetus to heal surgical scars or thermal burns would be the envy of a plastic surgeon. In these contexts at least, it would be more appropriate to consider the adult as a poorly functioning fetus.

Even when we accept that it is the fetus who is in command of the pregnancy, that it is mother, not the baby, who is the passive partner in the relationship, people might still feel that the fetus is nevertheless but a new superconductor of some endocrine orchestra, a mindless programmed robot controlling his mother. Nothing could be further from the truth.

As the fetus develops structures-including sensory structures-he uses them. Development of structure and development of function go hand in hand. Indeed, if the function cannot be served without developing the structure, equally, without the stimulus of function the structure does not develop properly. Further, we are aware in extrauterine life that every individual represents an interaction of nature and nurture, of environment and genetic endowment. The same is true in the uterus. The fetus does not live in a metabolic nirvana, or in a dark and silent world in a state of sensory deprivation. The uterus may buffer, filter, distort the outside world, but does not eliminate it. Stimuli do reach the baby and he responds to them.

We know that fetal movement is necessary for the proper development of bones and joints, that the fetus without room to move, or muscles and nerves to move with, is born with severe restriction of range of joint movements. We know that fetal comfort determines fetal position; that changes in maternal position provoke the baby to seek a new position of comfort; that contractions and external palpation provoke fetal movement; and that the fetus will repeatedly evade the sustained pressure of a microphone or recording instrument. We know how babies change ends in the uterus while they still have room-they propel themselves with their feet, either frontwards or backwards, and how they change sides-with an elegant longitudinal spiral roll, rotating first their heads, then their shoulders, and finally their legs.

In early pregnancy the fetus is free to move as he pleases, and he does precisely that. He can turn complete flips in one and a half or two seconds. In late pregnancy, with increasing fetal bulk and diminishing amniotic fluid volume, there is less choice, but fetal comfort determines which way the baby will lie in late pregnancy and present in labor. Thus the fetus is responsive to touch and pressure, simple facts confirmed by an obstetrician who has ever stroked the palm of a prolapsed arm and elicited a grasp reflex, or the sole of a footling breech and observed the upgoing toe.

Q: Is this why, when you try sometimes to pick up the heartbeat of, say, an 8-week-old fetus, one minute you can hear it and the next you cannot?

A: Largely that is determined by the movement of the fetus at that stage of pregnancy. The baby moves freely about the uterus, and the techniques using ultrasound to pick up a baby are critically directional. It is rather like trying to keep an opossum or rabbit in the beam of a torch spotlight at night. However, we have also noted when turning up the amplification of a baby's heartbeats that the baby is startled by its own amplified heartbeat so that one gets a startled reaction movement from the baby.

Q: Is that even at this early stage of 8 to 10 weeks?

A: No. The earliest we have noted fetal response to sound is in fact 23 weeks gestation. This has been determined by the fact that until recently we were restricted to techniques, particularly X-ray, by which we had a skeleton of something to visualize in the fetus. Now with ultrasound there is an opportunity to see how much earlier in pregnancy it is possible to extend the same observation.

Q: In the case of an 8- to-10-week fetus, if you apply pressure will it tend to try to get out of the way?

A: Normally it would be extremely difficult, apart from putting a foreign instrument or needle into the uterus to apply pressure, but with a fetus at that maturity you have a very small fetus in a larger capsule of fluid. However, as the famous work of Dr. Davenport Hooker shows, in his many thousands of feet of film, babies at this maturity are responsive to touch.

The fetus also responds violently to painful stimuli-needle puncture and injection of cold or of hypertonic solutions- stimuli which you and I find painful, children will tell you are painful, and the neonate, to judge from his responses, finds painful. There is little relationship between the velocity of a movement, for example, of a single limb and the energy involved in a major fetal movement like turning over.

We have photos showing the remarkable flexibility of the fetus, such as doing a trick you and I cannot do, which is to sit down there with a 180-degree longitudinal twist in our spine. This is called a corkscrew fetus. We have an extensive collection of photos of corkscrew fetuses. It is hard to see why any baby would elect to lie with a 180-degree twist in his spine. This was puzzling at first. Then we had the idea that the corkscrew fetus was a baby caught in the act of turning over. We proved this by taking additional photos. Invariably we found that in a subsequent photo the corkscrew fetus would then have shipped his spine across completely. He had turned from one side to the other.

While babies still have room in the uterus, they usually turn themselves with their feet. Most push themselves around backwards, then an occasional one walks around frontwards.

We know that the baby may have his back to the left this afternoon and to the right this evening and to the left tomorrow morning. How does the baby get from side to side? Does he scramble around on his hands and knees? Does he get sloshed around and over in a tide of fluid or is he left behind when his mother rolls over? The answer is that fetuses turn over using the following mechanisms: they can rotate their head over their shoulders by their legs using this elegant longitudinal spinal roll, an elegantly coordinated movement.

There is nothing clever about this. Except for their flexibility, it is the way you and I turn over in bed at night and the way you and I would turn over in a swimming pool if we were floating on our backs. The interesting thing about observing this in the fetus is that if you read textbooks of development of locomotive action in the newborn, you find that babies are not supposed to turn over in the crib until about 14 to 20 weeks after birth. Yet we have photographs of babies in the uterus turning over with this mechanism 16 weeks before birth. Why do we not see this behavior in the newborn baby? Why, apparently, can newborn babies not do this? The baby obviously already has the development of the right reflex action. It is just that the trick is very simple in the state of neutral buoyancy, which is what the baby lives in before birth, but it becomes difficult or impossible against a newfound tyranny of gravity which the baby is subjected to at birth. It is not for another 14 or more weeks after birth that a baby has developed the muscular strength to control his head and trunk against the force of gravity and duplicate this trick that he had done many months before birth.

Other photos show babies lying with their neck extended so that their face is in the opposite direction, with their neck extended and their entire spine extended so that their buttocks are about two centimeters (1 inch) off the back of their head, or with their entire spine extended and their hip joints extended as well. There is nothing wrong with any of these babies in spite of the impression you might get from looking at their photographs; they just choose to lie that way. After birth, you see many babies sleeping in the odd positions that they chose to rest in within the uterus prior to birth. You see the babies who have been extended breeches lying in incubators with their foot over like a safety pin, the same way we found them in utero five weeks before birth.

The discussions that have taken place relating to pain relief in childbirth have involved only maternal pain. Considering all that has been written by poets and song writers about the cries of newborn babies, you might think that newborn babies cried for fun. We think newborn babies cry for one reason only, because birth has been a stifling and often painful experience for the baby. We are getting around to the way of thinking that whether or not mother needs pain relief in labor, some babies might well be better off for it.

However, I have been told by advocates of abortion that we have no proof that the fetus actually feels pain. Strictly, they are quite correct. Pain is a peculiarly personal and subjective experience and there is no biochemical or physiological test we can do to tell that anyone is in pain-a phenomenon which makes it very easy to bear other people's pain stoically, which is an important point for obstetricians to remember. By the same token we lack any proof that animals feel pain. However, to judge from their responses, it seems charitable to assume they do. Were this not so there would be no point in having an organization like the Society for Prevention of Cruelty to Animals, and I for one would be unhappy to think we would withhold from the human fetus a charitable consideration we were prepared to extend to animals.

Q: The question, then, of pain felt by the fetus-it is your personal opinion, I gather from what you say in your paper, that in effect the fetus does feel pain?

A: I can only say that the fetus responds violently to stimuli that you and I would find painful. Bertrand Russell once remarked that a fisherman had told him that fish had neither sense or sensation, but how he knew that the fisherman would not tell him.

Q: Well, what is the earliest stage at which you have observed this apparent violent reaction on the part of the fetus?

A: In just over 16 weeks, carrying out amniocentesis for very early and severe RH hemolytic disease. Then again, response to irritation, for instance a bristle, has been observed much earlier than this by Davenport Hooker in his monumental film footage of mechanical behavior reponses of very early miscarried babies.

The fetus responds to sound and light in utero. The fetus is startled by flash photography of a pregnant abdomen, and with a fiber-optic conduit and photo-multiplier we can detect the shadow cast by the fetus on the posterior uterine wall. In utero the light is shifted far to the red end of the spectrum and the fetus is using only his rod, or low-light intensity, vision, but if there is any light present at all there must be activation of visual pathways, because single-rod cells respond to single photons. The fetus lacks any images and sufficient light to practice cone vision, so that at birth he can see but does not know what he is looking at. Confident recognition of images takes five to eight months of extrauterine life to acquire.

With sound it is different, because intrauterine sounds have pattern and a spectral composition not very different from extrauterine sounds, and the fetal inner ear or hearing mechanism is of the same magnitude and therefore responds in the same frequency range as children's or adults' ears.

If the hearing structure in the child grew with the child to adult size, then babies and children would hear in a different frequency range from adults, and the communication gap between generations would be perhaps even wider than it is already.

It is easy to demonstrate fetal responses to external sound, and audiometric curves may be constructed by noting changes in fetal heart rate to pure tones presented by hydrophone or air microphone.

We have done these tests to reassure deaf mothers, for instance, during pregnancy, that their fetus did in fact hear.

The fetus lined up under an image intensifier in a quiet room is startled by a sudden noise-the dropped pot or human voice, including his mother's. He responds to the tympanist's contribution or an orchestral performance, and to the dentist's turbine drill. Both habituation and conditioning have been demonstrated.

Habituation is the phenomenon by which you can play someone a signal and he starts; you play it again and there is not so much response; you keep it up, and after a while he starts to ignore it. The baby does precisely this. Conditioning is where, having given one stimulus to a baby, you give a second one, and after a while you get a response to the first signal which you formerly were only getting to the second.

However, it is not simple external sound which bombards the fetus. The pregnant uterus itself is a very noisy place. The loudest sounds to which the fetus is exposed are maternal borborygmi peaking to 85 to 90 decibels, about the intensity of sound of traffic in a busy city street. Reaching and below 55 decibels the content is richer in pattern and meaning, the intermittent voice and the all-pervading vascular bruits pulsing in synchrony with maternal heartbeat in the great arteries supplying the uterus. We do not think it entirely chance that babies are lulled by holding them to your chest; or the old wives' alarm clock; or the modern magnetic tape of a heartbeat; that the tick of a grandfather clock in a library is a reassurance rather than a distraction; that people asked to set a metronome to a rate which 'satisfies' them will pick a rate in the 50- to 90-per-minute range; and that the majority of drum rhythms in the world reflect the measured beat of a human heart. We think this rhythm is deeply imprinted on human consciousness from fetal life.

Q: What is the earliest age in development that you have observed response to sound?

A: Personally, 23 weeks. To my knowledge the process has not been looked at earlier in this situation. Again, one has to distinguish a living fetus in the uterus, and if pregnancy continues, and therefore one is apparently dealing with a baby, as it were, in good shape, as distinct from the very early miscarried baby who is a living but unfortunately dying baby.

The fetus drinks amniotic fluid in a phasic pattern from at least as early as eight weeks' gestation. By the third trimester there is a fascinating variation, some babies coyly drinking 10 ml per hour, and others boozing away at 90 ml per hour.

Many women have noticed fetal hiccups. They were not aware of what they were, and some have been quite worried, particularly if there is an epileptic somewhere in the family cupboard. "Could the baby be having a convulsion, doctor?" These convulsions have been described, but they are extremely rare. Hiccups are very common indeed, and women are very much reassured to be told what they are. Some have already guessed.

There are two interesting things to know about the drinking of unborn babies: their variability, and also the general fact that large, well-nourished babies drink at a high rate, whereas little skinny babies, with numerous exceptions, tend to drink at a low rate. But what is even more interesting about this is that it correlates beautifully with independently assessed feeding

performance in the nursery. Most nurses and mothers are well aware that some babies really know what their mouth is and what it is for, whereas others take 20 or 30 minutes or more to feed, drinking during that time an amount any self-respecting baby would dispose of within two or three minutes. The interesting thing is that the good drinkers in utero are the good drinkers in the nursery and the dainty, tedious swallowers in utero are the tedious one out of the uterus as well. In other words, not just physical traits, not just medical conditions, can bridge birth. The behavior traits also bridge the birth.

Now that we are in a position to measure the swallowing rate, we can also check on the influence of other things on swallowing in utero, for instance the flavor

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