Perspectives in Physiology

Published on behalf of The American Physiological Society by Springer

Lawrence D. Longo

The Rise of Fetal

and Neonatal
Physiology
Basic Science to Clinical Care
Perspectives in Physiology

Published on behalf of The American Physiological

Society by Springer

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Lawrence D. Longo

The Rise of Fetal and

Neonatal Physiology
Basic Science to Clinical Care

Foreword by John R.G. Challis

Lawrence D. Longo
Center for Perinatal Biology
Loma Linda University School of Medicine
Loma Linda, CA, USA

ISBN 978-1-4614-7920-8 ISBN 978-1-4614-7921-5 (eBook)

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Dedicated to the memory of my father,
Frank Albert Longo (1897–1987),
and to Robert Elder Forster II,
of the Department of Physiology,
University of Pennsylvania. Each was
an incomparable inspiration and mentor
with abundant wisdom, who helped me
to learn what is important in life.
Foreword

The 1960s and 1970s were wonderful times to be doing research in fetal physiology.
To be in Oxford during that period was to be in one of the great centers of research
activity. I had the good fortune to be at the right place at the right time. Oxford was
our Camelot. Colleagues from around the world spoke enviously of one having a
“Been to Oxford” (BtO) degree. Geoffrey S. Dawes (1918–1996), Director of the
Nuffield Institute for Medical Research in Oxford, was undoubtedly the father fig-
ure (some said godfather figure) of fetal physiology in his day. His contributions
were of such significance that his position as a giant in the field was unassailable.
He had built upon the foundations laid by Barcroft, Eastman, Barron, and those oth-
ers who had preceded him to define a new field of investigation.
Why was Oxford so special? Partly, it was the lure of that venerable city, and the
Oxford “way” of doing things. Partly, it was the coming together of a remarkable
group of outstanding and enthusiastic young physiologists working with some
extraordinary senior leaders and visitors. There was a critical mass of colleagues
and supportive technical staff, and a buzz around Geoffrey’s Nuffield Institute.
Time was immaterial, there always was someone working at a new problem or
ready to share a new finding. Crucial was the realization that the fetus as not just a
little adult, but was a distinct, viable entity, with a separate and often quite different
physiology. It was clear that everything that we knew about adult physiology did
not necessarily apply to the fetus, and needed to be rediscovered or at least reexam-
ined. Every day seemingly brought another discovery, another surprise. The insti-
tute was adjacent to the University of Oxford’s John Radcliffe Hospital and its
Nuffield Departments of Obstetrics and Gynecology and of Pediatrics. The leaders
of those departments were sympathetic towards research, and it was quickly clear
that this new science had immediate application to clinical practice in obstetrics and
pediatrics. The proximity of the institute to the clinical wards, to enthusiastic young
physicians, and our attendance at clinical rounds facilitated this process. We were
doing translational research and knowledge exchange before it became fashionable,
without even the need to give it a fancy name.

vii
viii Foreword

Without question, the simultaneous and coincidental development of an array of

new techniques was crucial to the opening of this new field. There was a rapid
advance from the study of the sheep fetus in short-term acute experiments, ex utero,
to extraordinary studies with the in vivo chronically catheterized fetal lamb. In
1969, Geoffrey Thorburn had published with John Bassett the rise in plasma corti-
sol concentrations that preceded the onset of birth in chronically catheterized fetal
sheep, and later had helped establish that procedure in Oxford. I shall always
remember that great physiologist and chronicler of the placenta, Emmanuel Ciprian
Amoroso, returning to the ARC Institute of Animal Physiology at Babraham,
Cambridge, from a trip to Australia. I was a graduate student at that time, and Amo
lost no chance to sing the praises of Geoff Thorburn and this remarkable advance.
Little did I know that in 4 years I would be working with him and I could not have
guessed at the influence that he would have on my own career. But, let us get back
to Oxford. Mention also must be made of Derek Wyatt, an outstanding physicist and
member of the institute, who was crucial in developing many of the flow probes that
would be used in these new “fetal” preparations. The new technique of radioimmu-
noassay had just been developed to the point that we could measure multiple hor-
mones in very small samples of fetal blood. We had techniques for recording
electrical signals from the fetal brain in utero, we could measure blood flows and
distribution, and we could ask the “undisturbed fetus” questions of critical clinical
importance: “how are you? how are your blood gases? what are your glucose lev-
els?” We could measure fetal responses to perturbations, infusions of hormones and
drugs, follow physiologic changes through the birth process and into the newborn
period. I remember well the time that we were making the first measurements of the
rise in Prostaglandin E2 in the fetal circulation before birth. I proudly showed the
print out from the scintillation counter to Geoffrey Dawes. He was unimpressed.
I had not explained that as the counts went down, the concentration was going up.
But then he asked whether this might have anything to do with the decline in fetal
breathing movements that occurs at that time, and suddenly I had his full attention,
and a year’s worth of suggested experiments!
Our scientific advances were helped by good-natured fellowship and by compe-
tition. There was great collegiality and daily debate at morning coffee and afternoon
tea held around the round table in the lobby of the institute (see my letter to LDL in
Chap. 20). Here Geoffrey Dawes was masterful and a wonderful stimulator of new
ideas. There was also great debate at the White Hart Pub at lunch time and after
work in the evening. It is strange that today we have to force these interactions with
scheduled meetings. But, there was also competition. In the early 1970s there were
three related Medical Research Council (MRC) program grants at Oxford, led by
Geoffrey Dawes (GSD), Geoffrey Thorburn (the big G) and Alexander Cuthbert
Turnbull (later Sir Alexander; 1925–1990), respectively, dealing with parturition
and fetal physiologic changes near birth. The competition in research was and is
healthy. It helps to drive us forward. It also infuses an environment with measure-
able energy that leads to pride and excitement, and eventually to a legacy of accom-
plishment. It helps create leadership and lifelong friendships and networks. It was
an environment that brought Oxford together at international meetings, particularly
Foreword ix

in exchanges with other major centers that were emerging at that time. Importantly
locally amongst these was the excellent group in Cambridge of Robert Comline,
Marion Sliver, successors of Sir Joseph Barcroft in the perinatal research field, with
the young Peter Nathanielsz and Abigail Fowden (although, as a Cambridge gradu-
ate, I was just a little uneasy with the light blue–dark blue conflict). The University
of Oxford Nuffield Department of Obstetrics and Gynaecology photographs from
1974 to 1975 are so revealing of the environment at that time. Virtually every one
of the junior staff members and trainees in those pictures went on to hold a major
chair or a directorship later in their career, but as colleagues they have remained in
touch with each other, bonded by the Oxford experience.
The public environment was also “right” for doing fetal research. In the United
Kingdom, the MRC was enthusiastically supportive through staff appointments and
research grants; in the USA, fetal physiology was gaining momentum at the National
Institutes of Health. The media, the general public, and some key politicians wanted
to know about life and development in the womb. Preterm birth occurred in one in
ten pregnancies. At a time when we were just starting to learn about the regulation
of lung surfactant, the public wanted to know how to prevent preterm birth and how
to look after the premature baby. The landmark study of “Mont” Liggins and Ross
Howie on the use of glucocorticoids to prevent respiratory distress syndrome was
published in 1971. It resulted directly from studies of cortisol infusion into fetal
sheep, the perceptive insight of Mont Liggins, and minimal bureaucracy in moving
basic research into a clinical trial. Mothers wanted to know how the environment
might affect their baby. Research offered answers. The magic and mystique of the
environment inside the womb became mainstream reading. A black box was open-
ing quickly with new information based on excellent science. Politicians and fund-
ing agencies listened carefully and were extremely supportive.
But research happens in cycles. Often these last only 5–10 years. An area
becomes topical, a new approach offers a major advance and folk jump onto the
bandwagon, until the research becomes routine. For a short time, grant funding
committees and study sections look favorably on something that is cutting edge. It
may be a new field of research (such as fetal physiology) a new topic (prostaglan-
dins, insulin-like growth factors), a fascinating and important discovery (surfac-
tant), or the emergence of a new technique (the chronic fetal sheep preparation and
assay of hormone receptors). Fetal physiology seemed to happen in a way and at a
time that allowed a convergence of these different factors and approaches. The field
opened up technically, the translation (such as in fetal monitoring, stimulation of
lung surfactant, or surfactant therapy), was obvious in obstetric and neonatal prac-
tice, and that fuelled public interest and media support. Because there was a whole
field of fetal physiology to be discovered, the wave lasted a bit longer than many. In
many ways this was good. But I also believe that fetal physiologists lost the game
or only recognized it when it was too late for them, to the developmental biologists,
initially, and then to mice. We missed the fiscal reality of switching from sheep to
mice and we were slow to appreciate the power of mutating a gene and the ability
to knock in and knockout genes. Of course, we soon became useful in helping to
interpret phenotypes (and there was some very naïve phenotypic interpretation of
x Foreword

some early mouse knockouts), but the agenda had changed, and a new generation of
investigator was driving it.
The field of fetal physiology continues today, of course; that is the nature of sci-
entific waves. But, I think this is what Geoffrey Dawes meant by his oft (mis)quoted
comment about the major questions in fetal physiology being answered by the time
of his retirement. Most major questions had been addressed at a physiologic level,
and needed new genetic approaches to achieve further mechanistic advance. Geoffrey
also saw the emerging importance of understanding the fetal origins of adult disease,
and championed the meeting in Italy in 1989 where David J.P. Barker presented his
very early information to a group of fetal physiologists. If there was an obvious way
forward for fetal physiology, it was through understanding the developmental origins
of disease. This needed a physiologic approach but had to be coupled with applica-
tion of different ’omic techniques and epigenetics. But, many Ob-Gyn departments
had missed an opportunity to emerge as the hotbeds of university and hospital
research, as departments of developmental reproductive biology, combining integra-
tive physiology with cellular and molecular mechanisms of development.
Interestingly, the antivivisection movement was also a factor in the decline of
fetal physiology as we knew it. It easily generated more adverse press against
research with sheep and subhuman primates, than it did against research on mice.
New rules for the conduct of research, new animal requirements, and spiraling costs
have driven many classic fetal physiologists out of the animal house. Ironically, the
antivivisection movement and fiscal reality actually forced some sheep fetal physi-
ologists toward developmental biology, to develop new models and gain familiarity
with new molecular approaches. The new models of translational research that link
basic science to population biology and the health care systems will allow fetal
physiologists to flourish, and I am optimistic that we are still training a cadre of
needed and worthy successors.
Geoffrey Dawes became Director of the Nuffield Institute at age 30 in 1948; 5
years before Watson and Crick published the structure of DNA. At the time, he had
only eight publications to his name. This volume portrays him accurately. He was
an astute and critical investigator, maintaining the highest standards of scholarship
and expecting others to reach those same values. He was sometimes antagonistic.
He was harshly critical when he felt it justified, and he could be polarizing. But if
one matched his standard, worked hard and thoughtfully, one gained his respect.
You had won a friend, not just in science but for life. But if you had come up
through one of the other “schools,” it would always be that much harder, and to my
mind Geoffrey never accepted you in quite the same way. Over the years he devel-
oped a special affinity with Canada, and it has saddened me that our great Canadian
Universities did not recognize Geoffrey appropriately for that.
There was also a very compassionate side to Geoffrey Dawes that often went
unrecognized. I saw him go to extraordinary lengths to help a colleague with a
medical problem, or to assist a student in financial difficulty. He was kind and
thoughtful towards the institute staff, knew their names, and quietly would offer his
advice or assistance if he thought that it would be helpful. His trainees became his
extended family. He followed their progress with great interest and enthusiasm.
Foreword xi

He shared in the excitement of their discoveries and would enjoy the intellectual
discourse with them, clearly proud as they established their independence and fac-
ulty appointments. He was, of course devoted to his wife, Margaret. In this book
Christopher Redman describes Geoffrey coming into his office, discussing a new
finding, and leaving with the comment, “Isn’t this fun.” That vignette captures the
essential Geoffrey Dawes, enthused about good science, just like a small boy.
Finally, I must say a brief word about the author of this book, Lawrence D.
Longo. Larry is one of my heroes. He was there, seemingly at the beginning and is
still going strong! This volume chronicles the foundations built by the great historic
leaders, it tells how they laid the building blocks, and with Dawes and others cre-
ated a new field of investigation. It tells of the science and of the scientific societies
that underpin the discipline. Geoffrey was not there at the beginning of the Society
for Gynecologic Investigation in 1953, but he was clearly aware of the advances
being made by colleagues across the Atlantic. This volume is a scholarly account of
the development of the new field of fetal physiology and the translation of its
research to help mothers and babies. It is also a story of relationships, sometimes
fuelled by competitiveness, often fuelled by collegiality. It is a story with many
subtexts driven by the desire to acquire new knowledge. There was healthy compe-
tition, between Cambridge, Oxford, San Francisco, New Haven, Boston, and others
as they emerged as leaders and were then linked by new partnerships and the next
generation of scientists. There may be other descriptions of the growth of this field,
but it is unlikely that there will be any that captures the spirit, the excitement, and
the hope for mothers and their children as effectively as Longo has given here. In
this volume he has ensured his place as the great chronicler of a generation of inves-
tigators, and of a new approach to science. We are fortunate to have a colleague of
his intellect and modesty, of such insight into the accomplishment of others. This is
the story about how a field of research unfolds. But any new field needs its cham-
pion. For many, Geoffrey S. Dawes was that champion; a man of formidable intel-
lect, a great experimentalist, commanding yet compassionate, the leader of his time.

John R.G. Challis

Department of Physiology, University of Toronto, Ontario, BC, Canada
Department of Obstetrics and Gynecology, University of Toronto,
Ontario, BC, Canada
Simon Fraser University, Burnaby, BC, Canada
University of British Columbia, Vancouver, BC, Canada
University of Western Australia, Crawley, WA, Australia
Preface

History is always best written generations after the event, when cloud, fact and memory
have all fused into what can be accepted as truth, whether it be so or not” (Theodore Harold
White 1961, p. 188)

It was in the autumn of 2008 that Charles Evans Wood, of the University of
Florida, Gainesville, chairman of the program committee of the Fetal and Neonatal
Physiological Society, invited me to present the Geoffrey S. Dawes Memorial
Lecture at the 2009 meeting of that society. This lecture, initiated in 1998 to honor
Geoffrey Sharman Dawes (1918–1996), traditionally has been presented by an
established investigator who reviews some aspect of his or her studies during the
previous several decades. Rather than follow that formula, however, I developed a
different plan. As one interested in the history of ideas and the evolution of medi-
cine, for some time I had thought that it would be of value to document some of the
major issues and events associated with the genesis and development of the rather
specialized field of fetal and neonatal physiology. This was, in part, because of its
relatively brief history of less than a century, but also because of its enormous con-
tributions to understanding functional physiologic principles, and because of its
concentration on a vital and yet often overlooked aspect of biomedical science that
has made a profound impact on clinical medicine.
Among the seminal figures and major forces in developing the field of fetal and
neonatal physiology was Geoffrey S. Dawes of the Nuffield Institute for Medical
Research, University of Oxford. Trained as a physician, he dedicated his career to
understanding the physiologic and pharmacologic basis of important clinical prob-
lems relating to the developing organism. In a sense, this monograph could be
viewed as a case study of the role of an individual scientist, and many of the indi-
viduals he trained, in fostering, advancing, and shaping a given field of research.
Dawes’ scientific career covered a period of 55 years (1941–1996), during which
time he published over 220 papers. Included among these were a number of highly
cited scientific contributions, major reviews, introductions to symposia, and chap-
ters in books. As noted in the Foreword by John Richard George Challis, critically,

xiii
xiv Preface

Oxford’s Nuffield Institute served as a seedbed and salutary environment for the
education and training of a generation of bright young scientists.
Several individuals have asked why I would undertake such a formidable
endeavor. Actually, about a decade ago I had commenced working on an article
reviewing some of Geoffrey Dawes’ many contributions to life. We had been good
friends, meeting once or twice a year in Oxford, at international meetings, or my
home base in Loma Linda, and I had high regard for his work. Within several years
the project had expanded beyond a mere review. Then, following the 2009 Dawes
Lecture I realized that to place it all into perspective the enterprise would require at
least a small monograph. Several other reasons are relevant.
I probably am one of the last people alive who knew most of the leading figures
(with the exception of Huggett and Sir Joseph Barcroft) and lesser lights who con-
tributed to the evolution of ideas, methodologies, and the synthesis of the problems
and issues of developmental physiology. In addition, I have participated with many
of these notables in relatively small seminars, large conferences, National Institutes
of Health (NIH)-supported study sections, and various brainstorming sessions to
identify some of the vital issues and challenges that lie ahead.
Also over the years, I have conducted active correspondence with these individu-
als on a regular basis, and have had the pleasure of having a large number serve as
visiting scientists and seminar speakers at our Center for Perinatal Biology. Almost
without exception, these discussions have been an enriching experience.
Remembrance of many of their comments, experiences, frustrations, and insights,
can perhaps provide a thoughtful background for the vicissitudes in science, and the
life of the mind.
In addition, I elected to survey this field in an effort to assist young investigators,
both basic scientists in physiology as well as clinical researchers in perinatology—
fetal and neonatal clinical medicine—to gain an appreciation of their heritage and
what has gone before. With today’s World Wide Web, information technology, and
nanosecond communication, it is sobering to acknowledge that for many young
investigators, that which is more than a few years old is terra incognito. In general,
we live in an ahistorical age. Life is for Now—the Present. For most of the biomedi-
cal literature, reference citations in MEDLINE and PubMed go back only to the late
1940s. Thus for practical purposes, contributions before that time simply do not
exist. Our perpetual, annihilating present tends to sever our kinship with the past.
A sense of our history and tradition, however, argues for the continuity of thought,
experience, and feeling that accompanies the journey across the gulf of time.
Without our hieroglyphic scribbling, we lose not only the heritage of the past but
also our perspective and outlook, and our sense of who and where we are. With the
arrangement as presented, readers will have the ability to review quickly the back-
ground of a given problem in a single chapter or subchapter. In addition to the story
itself, perhaps of greatest value will be the accompanying references (each of which
I have perused myself, many in great detail), which they may read and evaluate for
themselves. In the present essay, I have attempted to present some of the epistemol-
ogy of the threads of scientific thought in the context of their times. Nonetheless, we
cannot ignore the words of Theodore Harold White (1915–1986) that opened this
Preface xv

Preface, and found in his Making of the President (White 1961). As the Harvard
pediatrician Clement Andrew Smith (1901–1988) observed regarding this aspect of
developmental physiology, growth in knowledge increases desire to understand its
special fields, and “this is particularly true of those periods during which life is more
dynamic. In no other brief span of existence can such profound alterations and
adjustments be studied …” (Smith 1945, p. 3).
Nonetheless, several caveats are in order. Although I have attempted to be rea-
sonably complete in considering the experimental studies of various investigators,
rather than exhaustive detail, my goal has been to stress the significance of their
contributions. Because of the many subjects encompassed by this field of research,
and its complexity and progress, the present essay makes no attempt to survey the
topic either in extenso or to the present day. Rather, it focuses on the role of some
individual scientists and those in their circle. Also because of the extent and vast-
ness to which this field has expanded, I have limited the review chiefly to the second
half of the twentieth century, considering issues that came to the fore during that
time. One might ask, where does history end, and contemporary physiology com-
mence. As can be appreciated, no history of a given field of discipline can be com-
pletely current and up-to-date. With each new day and passing week and month, the
advances move the frontiers and expand the horizons. With that in mind, for the
most part the present survey concludes about the time of Geoffrey Dawes’ death in
the mid-1990s.
As a corollary, so that this synthesis may be of value to investigators and others
with interest in this facet of science, the general bibliography is rather extensive,
and that for Dawes includes every paper of which I am aware he wrote (abstracts
are not included). The bibliography also includes a number of review articles and
volumes that the interested reader may consult to pursue a given topic in depth.
Although the over 2,000 references given may appear somewhat exhaustive, it con-
stitutes only a tithe of those papers published in the field during the period of this
survey. As such, I trust that these may be of value as a “taking-off” point for one
who wishes to explore the topic in greater depth. Importantly, rather than being
viewed as an encyclopedic list of names, dates, and isolated facts, I trust that these
would help to place the rise of fetal and neonatal physiology in its proper context.
In the paragraph that contains the opening quotation of Theodore H. White, he
notes, “What can be reconstructed now out of the contemporary recall of those
present must be seen as a fog-shrouded range of facts in which occasionally one
peak or another appears at a given hour of the day, but whose connection to the next
peak of facts is obscured by the clouds in between” (White 1961, p. 188). Or as
Napoleon Bonaparte (1769–1821) is alleged to have stated, “What then is … the
truth of history? A fable agreed upon.” A work in progress, history is best served by
constant reanalysis and rewriting, as opposed to a museum-quality sculpture in
resplendent marble.
An additional caveat is in order. For the most part, investigators in this field
worked in what Thomas Samuel Kuhn (1922–1996) referred to as canonical “nor-
mal science,” or “current paradigm.” That is, their studies were conducted within
a relatively restricted “model” or “system” with an accepted body of concepts,
xvi Preface

techniques, and methodologies that guided their thinking and worked to determine
the problems to be explored (Kuhn 1962). Several discoveries of what might be
regarded as “revolutionary science” or “paradigm shifts” occurred during this
period, such as that of the role of the fetal hypothalamic-pituitary-adrenal axis in
the initiation of labor, and the role of pulmonary surfactant in respiration. However,
despite a number of breakthrough advances, these were not typical of the period
as a whole.
That being said, a number of exclusions and gaps will be evident to the reader
versed in this discipline. From the standpoint of contemporary biomedical science,
for the most part, much of what is reviewed is general organ physiology, with little
consideration of advances in cellular and molecular biology. In fact, some would
regard this era as “nineteenth-century” descriptive science, phenomenology, or
worse. Nonetheless, it is important to recall that our present understanding is based
on previous description of fundamental facts and advances. In the words of Sir Isaac
Newton (1642–1727) and those before, “If I have been able to see farther than oth-
ers, it was because I stood on the shoulders of giants” (Merton 1965).
As is well known, “Clio’s many mansions” of history may be considered from a
number of standpoints: macro-, micro-, global, national, regional, local, social, cul-
tural, political, economic, biographical, and others. For the most part, the present
essay is a combination of technological science and internal history. It also includes
a fair bit of biography. I would like to think that not inappropriate, for as Ralph
Waldo Emerson, (1803–1881) observed, “All history becomes subjective … there
is properly no History, only Biography” (Emerson 1883, p. 5). As one who has spent
almost five decades as a laborer in this field, as noted an advantage in this approach
is that with the exception of the very earliest workers, I knew each of the contribu-
tors and many were dear friends. Thus, without sounding self-serving, I would like
to think that I have more than superficial insight into the developments and issues
involved. A limitation, of course, is that in this presentation only a cursory attempt
is made to include a number of related social, cultural, political, and economic
aspects. In part, the constraints of scholarly research, but also the limitations in
publication, require focus of narrative. Although considering chiefly internal events
and the “foreground,” I have attempted to place the work within the context of its
times. In this regard, I deliberately reject the concept of “continuity” in the develop-
ment of this field of research. Also, the present essay makes no attempt to resolve
certain battles of priority of particular innovation, or to impose “progressive” or
teleological schemes on this record. A “Whig” view of historical progressivism
(Butterfield 1965), this is not.
In preparing this work it has been inspiring to recall the fine, dedicated individu-
als and the accomplishments of those who have labored so diligently to develop this
field of research—to glimpse the greatness of some of the early achievements that
we now take for granted. Rather than being the definitive history, however, I trust
that it will be viewed as one perspective of fetal and neonatal physiology, albeit one
that is rather personal.
Preface xvii

In closing, I am particularly grateful to a number of colleagues, many of whom

worked at Oxford’s Nuffield Institute, who shared stories, anecdotes, and impres-
sions of their work and interactions with other colleagues. Importantly, I am in great
debt to Jimin Suh who worked indefatigably in helping to locate obscure references
and other sources, and to prepare this manuscript in its present form. She is abso-
lutely the finest associate for whom one could wish.

Loma Linda, CA, USA Lawrence D. Longo

References

Butterfield H (1965) The Whig interpretation of history. W.W. Norton, New York
Emerson RW (1883) Essays…. First and Second Series. A.L. Burt Co., New York
Kuhn TS (1962) The structure of scientific revolutions. University of Chicago Press, Chicago, IL
Merton RK (1965) On the shoulders of giants. A Shandean Postscript. With a Foreword by C.D.
Bowen. The Free Press, New York
Smith CA (1945) The physiology of the newborn infant. C.C. Thomas, Springfield, IL. 2nd edn,
1951; 3rd edn, 1959
White TH (1961) The making of the President, 1960. Atheneum Publishers, New York
Abbreviations

ACOG American College of Obstetricians and Gynecologists

ACTH Adrenocorticotrophic hormone
AGA Appropriate for gestational age
AVP Arginine vasopressin
BCE Before the common era
C Cervical (spine)
14
C Radioactive carbon
CBF Cerebral blood flow
CPAP Continuous positive pressure
CRH Corticotrophin-releasing hormone
CST Contraction stress test
CVRI Cardiovascular Research Institute (University of California San Francisco)
CYP Cytochrome P450 hormone
DNA Deoxyribonucleic acid
DOHaD Developmental origins of health and disease
dpc Days post conception
DPG 2,3-Diphosphoglycerate
E Embryonic day
ECoG Electrocorticogram
EEG Electroencephalogram
EFM Electronic fetal monitoring
EMG Electromyogram
FBM Fetal breathing movements
FGR Fetal growth restriction
FHR Fetal heart rate
FNPS Fetal and Neonatal Physiological Society
GnRH Gonadotrophin releasing hormone
[HbO2] Oxyhemoglobin concentration
Hgb Hemoglobin
HPA Hypothalamic pituitary axis
HVLF High voltage low frequency

xix
xx Abbreviations

IGF Insulin-like growth factor

IUGR Intrauterine growth restriction
IVC Inferior vena cavae
JSGI Journal of the Society for Gynecologic Investigation
K+ca Calcium sensitive potassium channel
KBE Knight Commander of the British Empire
L/S Lecithin sphingomyelin ratio
LDL Low density lipoprotein
LGA Large for gestational age
LH Luteinizing hormone
LTC Leukotriene
LVHF Low voltage high frequency
miRNA Micro RNA
mmHg Millimeters of mercury
MRC Medical Research Council
NAS National Academy of Sciences
NICHD National Institute of Child Health and Human Development
NICU Neonatal intensive care unit
NIH National Institutes of Health
NINDB National Institute of Neurological Diseases and Blindness
NLM National Library of Medicine
NO Nitric oxide
NRC National Research Council
NST Non-stress test
OCT Oxytocin challenge test
ONR Office of Naval Research
OSRD U.S. Office of Scientific Research and Development
P Postnatal day
PCO2 Carbon dioxide partial pressure
PG Prostaglandin
PO2 Oxygen partial pressure
POMC Proopiomelanocortin
PRS Perinatal Research Society
RDS Respiratory distress syndrome
REM Rapid eye movement
Rh Rhesus
RLF Retrolental fibroplasia
RNA Ribonucleic acid
ROP Retinopathy of prematurity
R-R Electrocardiographic R-R wave internal
SGA Small for gestational age
SGI Society for Gynecologic Investigation
SIDS Sudden infant death syndrome
S-T Electrocardiographic S-T segment
STAN ST-waveform analysis
Abbreviations xxi

SVC Superior vena cavae

SZN Stazione Zoologica di Napoli
tcPCO2 Transcutaneous PCO2
tcPO2 Transcutaneous PO2
Torr Torricelli—a unit of gas partial pressure
UCH University College Hospital, London
VEGF
. Vascular endothelial growth factor
V O2 Rate of oxygen consumption
Contents

1 Introduction ............................................................................................. 1
References ................................................................................................. 6
2 A Scientific Genealogy: Early Development
of Fetal–Neonatal Research.................................................................... 7
2.1 The Beginnings and Some Definitions ............................................ 7
2.2 Arthur St. George Huggett and Early Studies
of Fetal Physiology .......................................................................... 9
2.3 Late Nineteenth and Early Twentieth Century Contributions
by German Physiologists and Others ............................................... 10
2.4 Nicholson J. Eastman, Huggett, and Others
of the 1930s to 1950s ....................................................................... 15
2.5 Joseph Barcroft and a Widening of Interest
in Physiology of the Fetus ............................................................... 21
References ................................................................................................. 34
3 Oxford and the Development of Physiology, with Notes
on the Nuffield Institute for Medical Research .................................... 43
3.1 William Harvey and Seventeenth Century Physiology .................... 43
3.2 Other Early Oxford Physiologists .................................................... 47
3.3 Founding of the Royal Society......................................................... 49
3.4 The Oxford Medical School and Further Developments
in Physiology ................................................................................... 51
3.5 The Nuffield Institute for Medical Research ................................... 56
References ................................................................................................. 59
4 Geoffrey S. Dawes: A Life in Science..................................................... 63
4.1 Early Life and Work......................................................................... 63
4.2 Dawes and the Fetal Cardiovascular System:
The 1950s and 1960s ....................................................................... 68
References ................................................................................................. 75

xxiii
xxiv Contents

5 Fetal Asphyxia and the Primate Colony in Puerto Rico...................... 79

5.1 Historical Perspective ...................................................................... 79
5.2 Eastman and “Mt. Everest In Utero” ............................................... 82
5.3 William F. Windle and the Primate Colony at Cayo Santiago ......... 84
5.4 The Puerto Rico Studies of Asphyxia .............................................. 85
5.5 Virginia Apgar and Evaluation of the Newborn Infant .................... 89
5.6 In Summary...................................................................................... 91
References ................................................................................................. 91
6 The Pulmonary Vasculature and Dawes’ Foetal
and Neonatal Physiology… ..................................................................... 97
6.1 The Pulmonary Vasculature of the Fetus and Newborn................... 97
6.2 Dawes’ Foetal and Neonatal Physiology… ..................................... 106
References ................................................................................................. 108
7 Embryology and Early Developmental Physiology ............................. 113
7.1 Origins.............................................................................................. 113
7.2 Stazione Zoologica di Napoli........................................................... 118
7.3 The Discovery of Genetics ............................................................... 120
7.4 Embryology Becomes a Science ...................................................... 124
References ................................................................................................. 130
8 Some Aspects of the Physiology of the Placenta ................................... 137
8.1 Late-Nineteenth and Early-Twentieth Centuries.............................. 137
8.2 Mid-Twentieth Century to the Present:
Placental Fine Structure and Function ............................................. 143
8.3 The Uteroplacental Circulation, Transplacental Exchange,
and an Introduction to Placental Endocrinology ............................. 145
8.4 Pathology of the Placenta................................................................. 154
References ................................................................................................. 156
9 Governmental Support of Research in Fetal
and Newborn Physiology ........................................................................ 167
9.1 The Medical Research Council of Great Britain.............................. 167
9.2 The Medical Research Councils of Canada and Australia............... 172
9.3 The US National Institutes of Health ............................................... 173
References ................................................................................................. 180
10 Fetal–Neonatal Growth and Metabolism.............................................. 183
10.1 Early Studies .................................................................................. 183
10.2 Robert A. McCance, Elsie May Widdowson,
and Continued Studies of Growth and Metabolism ....................... 188
10.3 Neonatal Birthweights and the Small for Gestational
Age Infant....................................................................................... 194
10.4 Metabolic Rate ............................................................................... 199
References ................................................................................................. 200
Contents xxv

11 Epigenetics and the Fetal Origins of Adult Health and Disease ......... 207
11.1 Overview ........................................................................................ 207
11.2 A Brief Introduction to Epigenetics and Development .................. 209
11.3 The Dutch “Hunger Winter” of 1944–1945: A Case Study........... 212
11.3.1 Maternal and Infant Characteristics ................................. 212
11.3.2 Metabolic Sequelae .......................................................... 214
11.3.3 Cardiovascular Sequelae .................................................. 214
11.3.4 Related Sequelae .............................................................. 216
11.3.5 Neuropsychological Sequelae .......................................... 217
11.4 Other Antenatal Maternal Starvation Studies ................................ 219
11.5 A Perspective on the Fetal Origins of Adult Health and Disease .. 219
11.6 Critiques of the “Fetal Origins” Hypothesis .................................. 222
11.7 Malnutrition During Pregnancy as a Global Health Problem ........ 223
References ................................................................................................. 224
12 Some Aspects of the Developing Brain and Nervous System .............. 235
12.1 Overview ........................................................................................ 235
12.2 Developmental Neurogenesis ........................................................ 238
12.3 Cognitive Development.................................................................. 242
12.4 Cerebral Blood Flow in the Fetus and Newborn............................ 245
References ................................................................................................. 249
13 Related Developments in Fetal and Neonatal Endocrinology............. 257
13.1 The Beginnings of Reproductive Endocrinology and Medicine .... 258
13.2 Fetal–Neonatal Endocrinology ...................................................... 260
13.3 Developmental Neuroendocrinology ............................................. 264
13.4 Hormonal Regulation of the Timing of Birth ................................ 267
References ................................................................................................. 272
14 Further Developments in Fetal and Neonatal Physiology ................... 281
14.1 Pulmonary Physiology and Respiratory Distress Syndrome ......... 281
14.2 Corticosteroids and Maturation of the Fetal Lung ......................... 294
14.3 A Tribute to “Mont” Liggins.......................................................... 297
14.4 Blood and Hematology .................................................................. 300
14.5 Hyperbilirubinemia and Kernicterus in the Fetus and Newborn ... 305
14.6 Immunology ................................................................................... 306
14.7 Chronic Catheterization of the Fetus ............................................. 308
14.8 Cardiovascular Physiology............................................................. 310
14.9 Related Fields of Research............................................................. 313
References ................................................................................................. 313
15 Additional Clinical Aspects of Developmental Physiology .................. 327
15.1 Preterm Birth and Neonatal Intensive Care ................................... 327
15.2 Retinopathy of Prematurity ............................................................ 340
15.3 Transcutaneous O2 Measurements ................................................. 344
15.4 Thermoregulation ........................................................................... 346
xxvi Contents

15.5 Some Aspects of the Development of Maternal–Fetal Medicine ... 347

15.6 Pathology of the Fetus and Newborn ............................................. 354
References ................................................................................................. 355
16 Bioethical Issues in Research on the Fetus and Newborn Infant ....... 367
16.1 An Awakening of Responsibility ................................................... 367
16.2 The Emergence of Bioethics .......................................................... 368
16.3 The Massachusetts Experience ...................................................... 370
16.4 Later Developments ....................................................................... 372
References ................................................................................................. 374
17 Textbooks, Monographs, and Other Volumes on Fetal
and Newborn Physiology ........................................................................ 379
17.1 Volumes on Physiology of the Fetus and Newborn Infant ............. 379
17.2 The Josiah Macy, Jr. Foundation Conferences on Gestation ......... 384
17.3 New York Academy of Sciences Conferences
on Fetal Homeostasis ..................................................................... 385
17.4 Essays in Perinatal Medicine ......................................................... 387
References ................................................................................................. 388
18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis
in the 1980s and Early 1990s .................................................................. 391
18.1 Early Studies of Fetal Breathing Movements ................................ 391
18.2 Fetal Breathing in Humans ............................................................ 398
18.3 Early History of Fetal Heart Rate Monitoring ............................... 402
18.4 Subsequent Studies on Electronic Fetal Heart Rate Monitoring ... 405
18.5 Some Contemporary Developments .............................................. 407
References ................................................................................................. 410
19 Dawes’ Contributions to Symposia and a Summing Up...................... 421
19.1 Ciba Foundation Symposia ............................................................ 421
19.2 The Barcroft Centenary Symposium ............................................. 425
19.3 The “Dawes Symposium” and Others ........................................... 426
19.4 A Summing Up by Dawes ............................................................. 428
References ................................................................................................. 430
20 Dawes as a Mentor: Reminisces of Former Graduate Students,
Postdoctoral Fellows, and Associates .................................................... 433
References ................................................................................................. 460
21 Early Years of the Society for Gynecologic Investigation, the Fetal
and Neonatal Physiological Society, and Several Other Groups ........ 463
21.1 Beginnings of the Society for Gynecologic Investigation ............. 463
21.2 Journal of Gynecologic Investigation/Reproductive Sciences ....... 465
21.3 The Fetal and Neonatal Physiological Society .............................. 470
References ................................................................................................. 476
Contents xxvii

22 Epilogue ................................................................................................... 477

22.1 The Adventure of Science .............................................................. 477
22.2 Fundamental Research, Clinical Medicine
and the Role of the Physician–Scientist ......................................... 483
22.3 Fetal and Neonatal Physiology and Its Relation
to Physiology in General ................................................................ 485
22.4 Fetal–Neonatal Physiology and the Future .................................... 487
22.5 What Lessons are to Be Learned? .................................................. 489
22.6 Conclusion ..................................................................................... 495
References ................................................................................................. 495
23 Bibliography of Geoffrey S. Dawes ....................................................... 499

Name Index ...................................................................................................... 513

Subject Index ................................................................................................... 521
Chapter 1
Introduction

Some Divines count Adam 30. yeares old at his creation, because
they suppose him created in the perfect age and stature of man;
and surely wee are all out of the computation of our age, and
every man is some moneths elder than hee bethinkes him; for we
live, move, have a being, and are subject to the actions of the
elements, and the malice of diseases, in that other world, the
truest Microcosme, the wombe of our mother…. In that obscure
World…, our time is short, computed by the Moone; yet longer
than the dayes of many creatures that behold the Sunne, our selves
being not yet without life, sense, and reason; though for the
manifestation of its actions, it awaits the opportunity of objects;
and seemes to live there but in its roote and soule of vegetation:
entring afterwards upon the scene of the world, wee arise up and
become another creature….
(Sir Thomas Browne 1642, 1964, p. 38)

In his “Thoughts on the evolution of a scientific problem,” Sir Cyril Norman

Hinshelwood (1897–1967), Dr. Lee’s Professor of Chemistry and Fellow of Exeter
College, Oxford, observed “the scientific aspiration towards the understanding of
Nature represents one of the great movements of the human mind….” In this 1953
Presidential Address to the Science Masters’ Association of Oxford University,
Hinshelwood wisely noted, “Science is not the dryly syllogistic handling of obvious
facts. It is an imaginative adventure of the mind seeking truth in a world of mys-
tery.” He continued, “… and, as it happens, one of the most important steps is almost
always that made by people who have the vision to realize that certain phenomena
raise questions of unusual interest. And it may be that the first tentative answers to
these questions go further along the road than the latter amendments simply because
they provide the motive and occasion for the key discoveries” (Hinshelwood 1954,
pp. 300–301). A decade later in his 1965 Presidential Address to the British
Association for the Advancement of Science, Hinshelwood noted that “at all the
boundaries of science we come up against what are probably the inherent limita-
tions of human understanding. At the edge of biology we meet the chasm between

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 1
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_1, © American Physiological Society 2013
2 1 Introduction

what science describes and what the mind experiences…” (Hinshelwood 1965, p. 355).
George Santayana (1863–1952) observed, “Science is nothing but developed
perception, integrated intent, common sense rounded out and minutely articulated”
(Santayana 1906, p. 307), and Sir Winston Leonard Spencer Churchill (1874–1965)
is alleged to have echoed a somewhat similar theme in a lighter manner, “Science is
no more than organized curiosity” (Priestley 1957, p. 148).
Science also has been defined as the observation, identification, description,
experimental investigation, and theoretical explanation of natural phenomena. As an
intellectual exercise it continues to expand, both in breadth of inquiry, and in the
depth to which questions are explored. Science extends from the outer limits of cos-
mology to the molecular, atomic, and subatomic basis of existence. The Latin word
scientia is derived from sciens the past participle of scire, to know. As stressed by
George Alfred Leon Sarton (1884–1956) of the Johns Hopkins University, science is
the only field of intellectual activity that is progressive (Sarton 1927–1948, 1937,
1952). He later reemphasized this view.
The history of science may be defined as the story of the gradual unveiling of objective truth
and of the conquest of matter by mind, it describes the age long and endless struggle for
freedom of thought …. The history of science is one of the essential parts of the spiritual
history of mankind, the other main parts being the history of art and of religion. It is not
more important or more enlightening than these other parts, but it differs from them in that
the development of knowledge is truly cumulative and progressive … if we would explain
the progress of mankind, the history of science should be the very axis of our explanation.
(Sarton 1957, pp. 1–2)

Midway between the extremes of the infinitesimally expansive cosmos to that of

the infinitesimally minute subnuclear particle, is the human being, Homo sapiens,
that sentient creature that observes, contemplates, and wonders. As the study of vital
life processes and functions, the discipline of physiology (from the Greek physis
“nature” or “origin” and logia “the word” or “study of”), lies at the core of an inte-
grated understanding of biological function. Unique among the biomedical sciences,
physiology is the study of the dynamics of life, describing the vital functions of living
organisms, their tissues and cells. As a consummate example of reductionism, the
science of physiology includes integrative function of the whole body, and its sys-
tems organs, cells and molecules. That is, critical to a reductionist approach is that of
integration of the sum of the parts into a greater, global view of the body. Claude
Bernard (1813–1878), the great nineteenth-century Parisian biologist-physiologist
was an articulate proponent of this concept. Among his contributions, he asserted the
integral importance of the milieu intérieur [internal environment], and the role of
physiologic functions in maintaining the constancy of organs and their constituents
(Bernard 1878). In his The wisdom of the body, Walter Bradford Cannon (1871–
1945) championed the view of homeostasis of the milieu intérieur (Cannon 1932).
From the standpoint of ontogeny, one can inquire into the critical features of
development and their functional capabilities that give rise to the individual being
who can utilize his/her endowment, gifts, and abilities, to experience a full life, liv-
ing, loving, cherishing, and contributing. This constitutes the republic of fetal and
neonatal physiology. Although limited, in terms of the planetary systems, galaxies,
1 Introduction 3

and expanding universe of science, the field of developmental physiology goes back
several centuries. As noted in this synopsis, I would like to consider some aspects
of this history as a case study. That is, the manner in which, with sequential and
parallel discoveries, persons of more than average ability came together, bringing
different backgrounds, talents, and expertise, to ask critical questions. And by dili-
gence and persistence, often in the face of adversity, and not necessarily in agree-
ment, these individuals innovated, developing unique models, and opened new
vistas to explore. With these contributions, novel ways of thinking occurred in rea-
soning and reflecting upon a given subject. As acknowledged by others, history is
difficult to evaluate, even when well documented records are available. Its explora-
tion has a way of keeping us humble. In interpreting historical events and phenom-
ena, it is important to attempt to know the mind set and goals of those involved.
Thus, in the present survey, insofar as possible, I have attempted to enlist and record
the opinions of the key investigators in the evolution of this field.
By definition, fetal and neonatal physiology encompasses events from early
embryonic development through full development of the fetus, and includes the
profound changes at the time of birth, and the first month of life as a newborn infant.
Growth and development are a function of both genetic and environmental factors,
and these represent a continuum of change that serves to maintain homeostasis of
the organism. As an example, the history of research on the fetal circulation, which
is valid for the field of fetal physiology in general, has been divided into four eras:
the anatomical period from the time of Galen [Claudius Galenus] (131–201 CE) of
Pergamum [also Pergamon], those contributions from the time of William Harvey
(1578–1657) onward, the period of anatomy and anatomical-based physiological
hypotheses, and the era of hypothesis-based experimental research which com-
menced in the mid-to latter-nineteenth century (For instance, see Barclay et al. 1944).
In addition to increasing basic understanding of fundamental biochemical and
physiologic mechanisms, a critical aspect of advances in fetal and neonatal physiol-
ogy has been its many contributions to clinical medicine, both obstetrical perinatol-
ogy and pediatric neonatology. It is by such research that patient care for the gravid
mother, fetus, and newborn infant have advanced beyond blind empiricism.
Importantly, the field is a model of translational biomedical science at its best. As
suggested by the subtitle, beyond its contributions to basic science fetal and neona-
tal physiology is exemplary in serving as a bridge “from bench to bedside,” to
advance clinical care. In an attempt to present some of the advances in translational/
clinical science, and to engage a broad audience, from undergraduate to graduate
students, medical students to practicing physicians, I have included a number of
related contributions in reproductive medicine such as development of the fetal/
newborn brain, endocrinology, pulmonary and cardiovascular biology. With the
wide interests of a diverse readership, the volume is organized so that one may
select those chapters relevant to ones interests.
In general, major contributions to science, the humanities, the arts, and other
areas of knowledge have originated from two processes. The first is conceptual. The
polymath Arthur Koestler (1905–1983), in his The Act of Creation, described this as
“the bisociation” of two ideas or areas of knowledge, which previously had not been
4 1 Introduction

appreciated to be related, igniting the mind of an original thinker. On occasion, such

associations may occur in an instant (Koestler 1964). The second is the detailed,
laborious, experimental testing of a new, innovative concept or hypothesis in an
effort to obtain the evidence that either will support or refute a given idea or ques-
tion. This stage may take years or decades. In speaking of art and its genesis, Walter
Gropius (1883–1969) who forged the utilitarian movement in architecture and fine
art known as Bauhaus [house of building/building school], observed that art
blossoms in rare moments of inspiration by the grace of heaven (Gropius 1970).
The same may be said for creative, innovative science.
In physiology, and almost all areas of the biomedical sciences, study of the adult
organism has preceded that of the fetus or newborn infant. In fetal and neonatal phys-
iology, the majority of contributions have appropriated major conceptual break-
throughs from general biology, biochemistry, or physiology, and applied them to the
developing organism. Because the fetus is in effect, an “astronaut in utero,” and the
newborn infant, particularly one that is markedly premature, is such a fragile organ-
ism, experimental studies to uncover fundamental mechanisms have been neither
easy nor straightforward. Thus, the field has been met with challenges from almost
every quarter. As the English poet and critic Samuel Taylor Coleridge (1772–1834)
observed, “The history of a man for the nine months preceding his birth, would, prob-
ably, be far more interesting, and contain events of far greater moment than all the
three-score and ten years that follow it” (Coleridge 1836, p. 244). And as in his poem
“C.L.M.” regarding our antenatal experience, John Masefield (1878–1967) wrote,
In the dark womb where I began
My mother’s life made me a man.
Through all the months of human birth
Her beauty fed my common earth.
I cannot see, nor breathe, nor stir
But through the death of some of her.
(Masefield 1927)

Fundamentally, scientific research looks to the future, to discover what can be

imagined and discovered. And yet there is no escaping its history. Perhaps more
than in other pursuits of the intellect, that which is possible in science critically
depends upon what has been. Of importance in this regard are not only the facts that
have been discovered, but the inspiration to be gained, and the appreciation of the
achievements of those who have gone before. At the same time science lays bare the
paucity of our knowledge. Oliver Wendell Holmes (1809–1894), Professor of
Anatomy at the Harvard Medical School, recognized this in his essay “Border Lines
of Knowledge in Medical Science.” He wrote, “Science is the topography of igno-
rance: From a few elevated points we triangulate vast spaces, inclosing infinite
unknown details …. The best part of knowledge is that which teaches us where
knowledge leaves off and ignorance begins” (Holmes 1891, p. 211).
An ineluctable consequence of the growth of science is that in essentially every
field of inquiry, as it becomes established, the subjects expand, become increasingly
complex, and divide into further subdisciplines. In part, reflecting intellectual
1 Introduction 5

insights, this process of fracture is a consequence of discoveries and advancements

in technology and instrumentation. In the late nineteenth century, Thomas Henry
Huxley (1825–1895) of Eastbourne, England, and one of the founders of the
Physiological Society in the UK, foresaw the inevitability of reductionism when he
observed that it would appear that, “… the scientific, like other revolutions, meant
to devour its own children; as if the growth of science tended to overwhelm its vota-
ries; as if the man of science of the future were condemned to diminish into a nar-
row specialist as time goes on” (Huxley 1864; Bibby 1967, p. 234). In considering
special features of biological science, Huxley observed, “… Physiology is the
experimental science par excellence of all sciences; … that which affords the great-
est field for the exercize of those faculties which characterize the experimental phi-
losopher …” (Huxley 1864; Bibby 1967, pp. 53–54).
In this volume, I have striven to chronicle those discoveries and related matters
that were of most importance and relevance. Although attempting to remain free of
bias and give full justice to every vital contribution, I appreciate that as a lone author
my perspective is less than perfect. What follows is a singular view of the anteced-
ents of this field of physiology, that of the fetus and newborn infant. In particular,
for his role as a catalyst and synthesizer, I detail many aspects of the role of the
Oxford pharmacologist–physiologist Geoffrey S. Dawes who worked to develop
and mature this intellectual endeavor. Some might argue that others should be
chosen as a focus for the evolution of this discipline. I believe, however, that as a
pioneer who donned the mantle of his predecessors, by his indefatigable labors,
Dawes not only personally advanced the science, but did so through the influence of
the scholars who worked with him, many of whom went on to distinguished careers
at academic centers throughout the world.
Some have viewed the origin of this field in terms of a “big-bang” theory, e.g.,
that it commenced in a blinding flash of academic brilliance at the Nuffield Institute
in the early 1950s. As the present study documents, that is not quite the case. Albeit,
although this subspecialty of physiology matured during this period, its creation and
development is a long and complex story. In addition to many only minor break-
throughs, it includes digressions and side roads, blind alleys and dead ends, incorrect
ideas, and some degree of confusion.
In such an exercise, a number of general questions require consideration. Beyond
the discoveries and contributions of individual scientists, what are the major factors
that lead to development of a specialty/subspecialty in science? What is the role of
related fields of science in shaping development of a discipline? To what extent does
such development depend upon advances in instrumentation and technology? What
are the ways in which one can calculate the impact of particular scientists, their
academic departments, or institutes? Is it a function of the papers produced, those
that are the most highly cited, or the cadre of students, postdoctoral fellows, and
others, and their academic careers and productivity? What of the social–cultural
issues of the time/era under review? These with others are some of the questions one
must consider in exploring the fabric and detailed pattern of this or any other par-
ticular subject of biomedical science.
6 1 Introduction

Some specific questions in regard to this field also require consideration.

How did the field of fetal and neonatal physiology develop? What were the major
factors? Who were the key players? In what way did Geoffrey Dawes uniquely
contribute to the advance of this field of research? Who were some of the individu-
als he mentored? What have been some of the seminal contributions of the field to
clinical medicine in care of the pregnant mother and her newborn infant? What
factors have influenced the continued advancement of this field? What is the role of
the university environment and its culture? Quo Vadis, what is ahead for fetal–neonatal
physiology, what are its opportunities and what are its challenges?

References

Barclay AE, Franklin KJ, Prichard MML (1944) The foetal circulation and cardiovascular system,
and the changes they undergo at birth. Blackwell Scientific, Oxford, p 275
Bernard C (1878) Leçons sur les phénomènes de la vie communs aux animaux et aux végétaux.
Cours de physiologie générale du Museum d’Histoire Naturelle. Baillière et Fils, Paris
Bibby C (1967) The essence of T.H. Huxley. … And a foreword by Sir Julian Huxley. Macmillan,
London
Browne T (1642) Religio medici. Andrew Crooke, London. (Also Martin LC (ed) (1964) Religio
medici and other works. Clarendon Press, Oxford)
Cannon WB (1932) The wisdom of the body. W.W. Norton, New York
Coleridge ST (1836) The literary remains of Samuel Taylor Coleridge. Coleridge HN (ed), vol 1.
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Sir Hinshelwood C (1965) Science and scientists. Adv Sci 22:347–356
Holmes OW (1891) Medical essays, 1842–1882. Houghton, Mifflin, Boston, MA
Huxley TH (1864) Lectures on the elements of comparative anatomy; on the classification of
animals and on the vertebrate skull. J. Churchill, London
Koestler A (1964) The act of creation. Macmillan, New York
Masefield J (1927) The collected poems of John Masefield. W. Heinemann, London
Priestley JT (1957) Surgery, science and humanity. Can Med Assoc J 76:147–150
Santayana G (1906) The life of reason or the phases of human progress. Vol 5, Reason in science.
Charles Scribner’s Sons, New York
Sarton G (1927–1948) Introduction to the history of science, vol 1–3 [of 5]. Williams & Wilkins,
Baltimore, MD
Sarton G (1937) The history of science and the new humanism. Harvard University Press,
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Sarton G (1952) Horus. A guide to the history of science. Chronica Botanica, Waltham, MA
Sarton G (1957) Six wings: men of science in the Renaissance. Indiana University Press,
Bloomington
Chapter 2
A Scientific Genealogy: Early Development
of Fetal–Neonatal Research

Human life proceeds by stages. The life-periods of the human

individual are no less real and significant than the geological
ages of the earth or the evolutionary stages of life. Each stage
… is distinguished by a dominant feature, a leading
characteristic, which gives the period its coherence, its unity
and its uniqueness.
(Samuel Feldman 1941, p. 53)

2.1 The Beginnings and Some Definitions

From a broad perspective, the human life-span can be considered as two major
periods, prenatal life and postnatal life. By definition, the fetus in utero is a develop-
ing mammal or other viviparous vertebrate. The word fetus, however, is an adopted
Latin word which signified a “bringing forth, breeding, dropping, or hatching” of
young (Smith and Hall 2000, p. 296). By metonymy it came to mean the young
or progeny. Thus, strictly speaking a contemporary equivalent would be parturition
and neonate. By common usage the term has been pushed back in ontogeny, and in
humans, medical texts define this as the unborn young from the eighth week of
pregnancy following fertilization (or 10 weeks after the onset of the last menstrual
period), that time at which the major organs have been formed until the moment of
birth. In humans at 8 weeks, it is about 5 cm (2 in.) in length, weighs ~8 g, and the
developing head constitutes about one-half the total mass. From weeks 11–17 of
gestation the brain, heart, and other organs continue to develop, and subtleties
appear in the several structures such as centers of ossification in bones and develop-
ment of genitalia. At about 16 weeks, a woman who has been pregnant previously
will sense fetal movements, “quickening,” although this may not occur until about
20 weeks in a nulliparous (having not delivered before) woman. From weeks 18–27,
development continues with the appearance of many structures such as eyelashes
and eyebrows, finger and toe nails, and a fine lanugo hair that covers the body.

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 7
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_2, © American Physiological Society 2013
8 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

From weeks 28–40, nerve growth with myelinization continues, the amount of body
fat increases, the electrocorticogram takes on a cyclic pattern of low voltage high
frequency (associated with rapid eye movements and other muscular activity and an
increased rate of cerebral metabolism), alternating with high voltage low frequency.
At this time, the fetus is capable of life independent of the mother’s womb, and for
the most immature, survival has been enhanced greatly by advances in neonatology.
By 37 weeks of gestation almost all infants can survive independently of neonatal
intensive care.
At full term (40 weeks) the gravid [weighty] uterus with fetus, placenta, and
amniotic fluid weighs 5–7 kg. The fetus/newborn weighs about half of that total,
depending upon ethnicity, genome, size of the parents, parity of the mother, and
other factors, with males weighing about 100 g more than females. Rather than a
passive passenger in the drama of reproduction, the fetus plays a critical and
dynamic role in regulating its own growth, development, and, at the appropriate
time, its delivery into the world. The so-called “maternal-placental-fetal unit” con-
stitutes a vibrant, dynamic system of communication with exchange of nutrients
from the mother, production of vital hormones by both placenta and fetus (particularly
the pituitary gland and adrenal cortex), and other interactions. Only recently, is the
extreme complexity of these interactions being unraveled. Within the uterus, the
fetus experiences a position of protection from the external world, never to be expe-
rienced again in life (Reece and Hobbins 2007).
Rather than being just a “small adult,” in addition to its dependence for life upon
the placenta and its unique cardiac circulatory patterns, the fetus is distinct in many
other respects. As may be anticipated, gestation is associated with considerable
variation in rates of fetal growth and maturation, these being a function of factors
noted above, as well as that of the mother’s weight and body mass index, exposure
to poor diet and/or toxins (such as tobacco products, alcohol, recreational drugs),
altitude of residence, and other factors. Dysregulation of placental structure and/or
function, compromised utero-placental blood flow, and other issues may jeopardize
nutrient delivery from mother to fetus. Any of these may result in intrauterine
growth restriction (IUGR), the fetus being small for gestational age (SGA). During
the third trimester the developing organism undergoes some of its most vital
changes, with completion of the process of growth, development, maturation, and
remodeling that continues into the third decade of life. In contrast to many facets of
mammalian physiology which were fairly well understood in the mid- to late-
nineteenth century, the addressing of these mechanisms of the fetus and newborn
did not truly develop until the mid-twentieth century.
Not a physiologist, the physician, rhetorician Sir Thomas Browne (1605–1682)
of Norwich, Norfolk, England, whose words opened this essay, recognized the vital
importance of fetal development and that moment at which, “… wee arise up and
become another creature” (Browne 1964, p. 38), a time during which more changes
occur than Browne could have imagined. Beyond isolated studies, what has been
described as “the age of adventure” (McCance 1977, p. 134), and might be regarded
as the origin of the physiology of the fetus and newborn in its broadest sense, arose
in the late 1920s and 1930s in Great Britain. This included studies in biochemistry,
endocrinology, neuroscience, and related subject areas.
2.2 Arthur St. George Huggett and Early Studies of Fetal Physiology 9

2.2 Arthur St. George Huggett and Early Studies

of Fetal Physiology

As presciently observed by Samuel Robert Means Reynolds (1903–1982) the history

of fetal–neonatal physiology is the coming together of “Many Slender Treads…”
(Reynolds 1978). In this essay, Reynolds noted that one who must be recognized as
playing a vital role in this regard was Arthur St. George Joseph McCarthy Huggett
(1897–1968) (Reynolds 1978) (Fig. 2.2c). In the mid-1920s, at St. Thomas’ Hospital
Medical School, London, working with his chief John Mellanby (later Sir John;
1878–1939) and the senior obstetrician John Fairbairn (1868–1944), “Hugo,” as he
was known to his friends, became interested in the problem of development of regu-
lation and sensitivity of the respiratory center. In an effort to perform his studies in
fetal goats and sheep in as physiologic state as possible, with the fetus attached to
the placenta, he immersed the anesthetized mother in saline in a large bathtub that
he found discarded on the hospital grounds. Bunsen gas burners, placed beneath the
tub maintained the saline at body temperature. Huggett’s initial report presented the
first oxyhemoglobin saturation curves of the fetal blood of a mammal (Huggett
1927). From this time, until his death four decades later, Huggett contributed to a
number of areas of developmental physiology.
In his initial report, Huggett described studies during the previous century in which
investigators used pregnant sheep. He observed, “The sheep… has the necessary
requirements [for these studies] but is three to five times the price of a goat” (Huggett
1927, p. 375). Later, Huggett extolled the merits of this approach, so that one may “…
treat the unborn foetus as an entity and to study it at any foetal age at leisure. It has been
of particular service in study of the placental mechanisms, since retraction of the pla-
centa does not occur. It is … particularly suitable for foetal investigations, since, by
using large animals … the foetus is of a convenient size unobtainable in most laboratory
animals” (Huggett 1950, p. 102). By use of a Van Slyke manometric apparatus (which
only recently had been described; Van Slyke and Neill 1924), and Barcroft saturators
(Barcroft 1914), in goats anesthetized with urethane, Huggett first measured the fetal
oxygen and carbon dioxide dissociation curves, and attempted to determine the mecha-
nism by which these gases exchange across the placenta between maternal and fetal
blood. In umbilical venous and arterial blood, Huggett determined the oxygen contents
to equal oxyhemoglobin saturations of 45 and 17 %, respectively, and the O2 partial
pressures (PaO2) to equal 41 and 15 Torr, respectively. His fetal oxyhemoglobin satura-
tion curve determined by differential tonometry was, in fact, incorrect, showing an
abnormally low blood-oxygen affinity (a P50 of about 40 rather than 19 Torr). As noted
several decades later by Sir Joseph Barcroft (1872–1947), although Huggett did not
publish dissociation curves for the mother (and, in fact, few oxyhemoglobin saturation
curves for any creature were available at that time), Huggett’s fetal curves so differed
from any curves then known as “… to excite the curious” (Barcroft 1946, p. 166).
Huggett correctly noted the greater amount of carbon dioxide (CO2) in fetal blood than
that of the mother, and its relatively less effect in decreasing the oxygen affinity of fetal
blood (Bohr effect), compared to the adult. His determination of the CO2 equilibrium
10 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

curve was quite accurate. Based upon the maternal arterial to fetal arterialized O2
tension difference of about 45 Torr, and a similar difference in CO2 partial pressures
between the fetal umbilical arteries and the maternal vessels, Huggett concluded that
these gases crossed the placenta by diffusion rather than by active secretion, as was
believed by some investigators. In addition, by contrasting the O2 content of carotid
arterial blood with that of the umbilical artery, Huggett demonstrated the separation in
streams of blood in the fetal central circulation (Huggett 1927). Of critical importance,
Huggett’s studies stimulated investigation of the interrelations of fetal and maternal
blood oxygen affinity and capacity and the placental exchange of respiratory gases by
other workers over the next decade and more.
This is not the place to review Huggett’s life and accomplishments in detail. That
has been recorded by others (Brambell 1970). Upon completion of a medical course
somewhat abbreviated by World War I, in 1918 Huggett graduated from St. Thomas’
Hospital Medical School. Following a year in military service, with the award of a
Beit Memorial Fellowship, from 1922 to 1925 he undertook independent research.
With a background in study of the central nervous system and respiratory regulation
in the cat, he initiated studies of the fetal respiratory center, placental respiratory
exchange, and placental glycogen in the goat (Huggett 1927, 1929, 1930, 1955).
Huggett credited the influence of two professors, Fairbairn and Mellanby, for focus-
ing his interest on physiology of pregnancy and the fetus, and in addition to being
inspiring teachers, as having “something more” (Brambell 1970).

2.3 Late Nineteenth and Early Twentieth Century

Contributions by German Physiologists and Others

As has been documented elsewhere, during the latter half of the nineteenth century
German science became preeminent, with its universities serving as world-renown
centers for research and creativity (Blackbourn 1998; vom Brocke 1991). To under-
stand the origins of these developments, they must be placed within the context of
their time. Friedrich Wilhelm Christian Karl Ferdinand von Humboldt (1767–1835),
Premier Minister of Education, governmental functionary and diplomat, in 1810
founded the Humboldt University, Berlin, and worked to initiate a university system
that fostered research. During this era, the “Iron Chancellor” Otto Eduard Leopold
von Bismarck (1815–1898), first chancellor (1871–1890) of the unified German
Empire, also influenced the support and expansion of the universities and scientific
research. In particular, the latter part of the century saw growth of the sciences basic
to medicine, with establishment of university departments of bacteriology, pathol-
ogy, physiology, within which scientific research was preeminent. In part, this also
was the work of Prussian minister Friedrich Althoff (1839–1908) who in 1872 was
instrumental in refounding the University of Strasburg into the Kaiser-Wilhelm
University (with the return of Alsace-Lorraine to France following World War I, this
was renamed the University of Strasburg), and other institutions of higher learning.
By recognizing creative talent and supporting many departments and individual
2.3 Late Nineteenth and Early Twentieth Century Contributions by German... 11

investigators, Althoff expanded the university system. In many respects, development

of the research universities in Germany was a consequence of the recognition that
science, scholarship and education with advances in technology, contributed to the
economic development of the industrial revolution. These were seen as “the fourth
factor of production,” in concert with the traditional combination of land, capital,
and labor. Importantly, the rising demand for highly trained individuals contributed
to a related social and economic development (vom Brocke 1991).
This transformation of German intellectual life and culture actually had its origin in
the late eighteenth century Enlightenment, with the rise of literary and philosophical
debates and thinking. Rather than a single territorial state in the contemporary sense,
Germany consisted of a number of separate territories, with the chief loyalty of its
peoples to the church, trade guilds, and feudal lords. With the gradual dissolution of
the Holy Roman Empire during the Napoleonic Wars (1806), and creation of the uni-
fied German Empire under Bismarck, there developed renewed emphasis in the
humanities and science, as well as politics and military endeavors. A belief in
Erziehung und Bildung [formation or upbringing and education] was central to this
culture of progress. Support of the universities acquired its own momentum, with
development of academic disciplines and subdisciplines. In particular, following uni-
fication, the German state exerted leadership in education, including appointment of
teachers and professors and scholarly activity. In part, the goal of this advanced educa-
tional system was to produce model citizens and officials to maintain the administra-
tive organization and structure. Thus, education and research was regarded as a
“practical need of the state,” with high standards and expectations. Both cultural and
national optimism supported the concept of scholarship in essentially every field of
knowledge. In medicine and the natural sciences this included preeminence in physics,
chemistry, biology, physiology, microbiology, and related disciplines. Professional
specialization and scholarly research were given high priority (for discussion see
Blackbourn 1998).
Prior to Huggett by half a century, with his measurement of oxyhemoglobin
concentration being greater in the fetal umbilical vein than in the arteries, Paulus
[Paul] Zweifel (1848–1927) (Fig. 2.2b) then at the University of Strassburg, demon-
strated unequivocally that the developing placental mammal consumes oxygen pro-
vided from the blood of the mother (Zweifel 1876). At this time, the nature of
placental exchange was not understood, however. A common view held that the
fetus was merely an “organ” of the mother, consuming little or no oxygen, and that
except for its heart, it grows in an inactive state producing no heat, being warmed by
the mother’s metabolism. This concept was supported by the prior observation of no
apparent difference in the color of blood (e.g., its oxygen levels) between the umbil-
ical arteries and veins (Pflüger 1868). Although two centuries earlier William
Harvey had raised the question of how the fetus survives in utero without air (Harvey
1651), there existed no agreement on this matter. Several years later, Paul Bert
(1833–1886) first described the oxyhemoglobin saturation [HbO2] curve (Bert
1878). At Strassburg, because of somewhat limited facilities in the Frauenklinik
[Woman’s clinic], Zweifel worked in the Institute founded by Ernst Felix Immanuel
Hoppe-Seyler (1825–1895). A leader in physiological chemistry (Hoppe-Seyler 1881),
12 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

Hoppe-Seyler had great interest in hemoglobin, being the first to crystallize it and
give its name (Hoppe-Seyler 1864). To resolve questions as to the extent to which
the fetus consumed oxygen, and if so its source, Zweifel determined to measure the
oxyhemoglobin saturation in the umbilical artery and vein of the near-term pregnant
rabbit (Zweifel 1876). Based on his clinical experience in handling the pregnant
uterus and umbilical cord, in an effort to minimize the effects of exteriorization on
the umbilical vessels, with care he placed the rabbit in a warm saline bath, opening
the abdomen and uterus under water, and allowing the placenta to remain in situ
attached to the uterine wall. As noted, Zweifel first demonstrated the oxyhemoglo-
bin saturation to be considerably greater in the umbilical vein than the umbilical
artery. Upon asphyxiation of the doe, this difference disappeared, but reappeared
again upon resumption of maternal breathing (Zweifel 1876). As an aside, the tech-
nique of immersing a body in a warm saline bath in which to float internal organs,
had been described several years earlier for the study of the influence of the vagus
(tenth cranial, parasympathetic) and splanchnic (sympathetic) nerves on gastroin-
testinal motility (van Houckgeest 1872). There is no evidence that Zweifel was
familiar with this report, however. With his study, Zweifel established that, indeed,
the fetus consumed oxygen, and that the placenta served as a fetal lung (Zweifel
1876). This answered in a definitive manner the question posed by Harvey so many
years before, and opened the way for studies of fetal metabolism (See below and
Barron 1976, 1978).
The following year (1877), Nathan Zuntz (1847–1920) (Fig. 2.2a), in a combined
theoretical and experimental approach, also estimated the difference in several vari-
ables including O2 levels in fetal and neonatal blood of the rabbit. When subjected
to asphyxia, he observed that the fetus survived longer than the doe. He concluded
that per gram of tissue, the fetus required less oxygen than the mother. Again, in
part, this idea was based upon his observation that the fetus can derive its heat from
the mother. In sheep, Zuntz also demonstrated that in the absence of breathing fol-
lowing delivery the fetus could be kept alive if the umbilical circulation was intact
(Zuntz 1877). A decade later, Isidor Cohnstein (1841–1894) of Heidelberg and
Zuntz in Berlin used this technique in rabbits, guinea pigs, dogs, and sheep to
explore the question of the distribution of blood volume, hemoglobin and O2 con-
centrations between the placenta and the fetus, and the changes such as an increase
in blood content in the lungs, following birth in the newborn. In these studies, they
also demonstrated that withdrawing blood from the fetus decreased its blood pres-
sure significantly (Cohnstein 1884; Cohnstein and Zuntz 1884). Because the ages of
the fetuses were not given, the preparations were acute in terms of the mothers
being anesthetized, the fetus was dead in many instances and the methods were
questionable, some have viewed the results as problematic (Forbes 1955). In a fur-
ther study, Zuntz measured the decrease in maternal red blood cell count and hemo-
globin concentration during the course of human pregnancy (Zuntz 1884). Zuntz
went on to become chair of veterinary physiology at Berlin’s Königliche
Landwirtschaftliche Hochschule [Royal Agricultural College] (1881), and a leader
in high altitude physiology (Gunga 2009). One of the earliest to report on the ability
of the human fetus to survive anoxia was Eduard Friedrich Wilhelm Pflüger (1829–
1910) (Pflüger 1877).
2.3 Late Nineteenth and Early Twentieth Century Contributions by German… 13

Another who contributed to the physiological chemistry of hemoglobin and

blood gases was Thierry Wilhelm Preyer (1841–1897) (Fig. 2.1a), Professor of
Physiology at the University of Jena (Preyer 1871). For studies of respiration in the
fetal goat, he used Braam van Houchgeest’s and Zweifel’s technique of placing an
anesthetized near-term goat in a bathtub filled with saline at body temperature.
Following a hysterotomy incision, the fetus remained submerged and attached to
the placenta. A prolific writer, Preyer’s Specielle Physiologie des Embryo;
Untersuchungen ueber die Lebenserscheinungen vor der Geburt [Selective physi-
ology of the embryo; Examination of the life appearance before birth] helped to lay
the foundation of this field of research (Preyer 1885) (Fig. 2.1b). In many respects,
a review of embryonic development and its chemistry, particularly in the chicken
egg, this volume consists of nine major sections, most of which have sub-chapters.
These included those on the embryonic heart and circulation of blood, breathing and
first movements, nourishment and digestion, heat production, sensation, and growth.
A supplement includes three appendices, 552 references to the literature, and nine

Fig. 2.1 (a) Wilhelm Thierry Preyer (1841–1897). (b) Title page (1885). (c) Upper figure—
Schema of blood circulation of chick embryo on day 3 of incubation. Lower figure—Hen’s egg on
day 3 of incubation (Preyer 1885). (d) Human placenta and uterine wall at 5 months gestation,
showing amnion, chorion, villous trees, decidua, spiral arteries, and myometrium (Preyer 1885)
14 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

Fig. 2.1 (continued)

plates, all but the last of which were drawn by Preyer (1885) (Fig. 2.1c and d). Also
considered a founder of scientific child psychology, Preyer wrote Die Seele des
Kindes [The soul of the child], in which he arranged chronologically his observa-
tions on childhood psychological development. In this work he expressed his belief
that the fetus in utero develops with minimal external sensory stimulation (Preyer
1882). Ill health forced Preyer to retire in 1888 at only 47 years of age. Currently,
2.4 Nicholson J. Eastman, Huggett, and Others of the 1930s to 1950s 15

Fig. 2.2 (a) Nathan Zuntz (1847–1920). (b) Paul Zweifel (1848–1927). (c) Arthur St. George
Huggett (1897–1968)

the “Wilhelm Thierry Preyer Award” is presented by the European Society on

Developmental Psychology for excellence in research of human development (Geus
1975; Schröder and Young 1995).
The volume Physiologie des Fötus by Friedrich Schatz (1841–1920), Professor
of Obstetrics at the University of Rostock, was dedicated chiefly to placental pathol-
ogy of the twin to twin transfusion syndrome (Schatz 1900). Because an arterial to
venous anastomosis of the placental vasculature between the twins, in the majority
of such cases the recipient fetus is significantly larger and edematous, with a greater
blood volume and a fluid filled bladder. With a relatively high rate of urination into
the amniotic cavity, the mother often presents with polyhydramnios and goes
into premature labor (Schatz 1900). Other than detailing aspects of comparative size
of the twins and some of their bodily organs, their hemoglobin concentrations,
hematocrits, and details of the placental vascular anastomosis (see below), the volume
addresses little physiology per se. In a 233 page, four article report Schatz earlier
first reported on measurements of intrauterine pressures within the uterus of a non-
pregnant woman. With the use of a liquid-filled balloon he demonstrated pressure
waves from the fundus downward (Schatz 1872a, b, c, d). Other aspects of his life
have been reviewed elsewhere (Ludwig 2006).

2.4 Nicholson J. Eastman, Huggett, and Others

of the 1930s to 1950s

Throughout the ages, at the time of parturition a serious problem has been that of
asphyxia of the fetus and newborn. Because of his great interest in this issue, and
stimulated by the report of Huggett, in a series of studies on fetal blood gas charac-
teristics Nicholson Joseph Eastman (1895–1973) (Fig. 4.2a), professor of obstetrics
at the Johns Hopkins University in Baltimore, MD, initiated a series of studies on
16 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

umbilical cord blood gas values at the time of birth. He reported that in these vessels
the O2 capacity was 21 ± 1 ml·dl−1 as compared with 15 ± 1 ml·dl−1 for the mother.
(These values equal hemoglobin concentrations of about 16 ± 1 and 11 ± 1 g·dl−1 for
fetus and mother, respectively) (Eastman 1930). Eastman also first compared the O2
contents of umbilical venous and arterial blood at both normal vaginal delivery and
at the time of cesarean section under local anesthesia, values for the latter being 13.3
and 6.3 ml·dl−1, respectively, corresponding to [HbO2] values of 63 % and 33 %,
respectively (Eastman 1930). To determine the extent to which the fetus experiences
anaerobic metabolism, and how this may affect the onset of respiration at birth,
Eastman measured umbilical lactic acid concentrations at the time of normal and
operative delivery. He showed that, compared to the mother, these were within
normal limits, ~34 ± 3 mg·dl−1, being elevated only in association with asphyxia
(Eastman and McLane 1931). Subsequently, Eastman reported the first oxyhemo-
globin saturation curves for the human fetus and mother (as well as non pregnant
adult), giving P50 values of about 22, 22, and 32 Torr, respectively. In this paper, he
also reported the fetal and adult dissociation curves for CO2 (Eastman et al. 1933).
At this time, Gustav Haselhorst (1893–1955) and Karl Stromberger (1895–1981)
of the University of Hamburg-Eppendorf, reported much lower values on blood gases
of the human fetus, compared to the mother; however, methodological problems
probably account for their abnormally low values (Haselhorst and Stromberger 1930,
1931, 1932). Karl-Julius Anselmino (1900–1978) and Friedrich Albin Hoffmann
(1843–1924) of Düsseldorf, in papers on icterus neonatorum, also reported on the
fetal blood oxyhemoglobin curves (Anselmino and Hoffmann 1930, 1931). Because
these were determined at a Pco2 value near zero, however, they cannot be compared
with contemporary curves. In 1936, a group from Leningrad reported wide variation
in the positions of the human fetal oxyhemoglobin saturation curves at the time of
birth, which they ascribed to variations in pH (Leibson et al. 1936). Also about this
time, Jacob Roos (1887–1942) and Christiaan Romijn (1910–1988) of the University
of Utrecht, The Netherlands, in the cow confirmed the significantly greater O2 capac-
ity of blood of the fetus, compared to the adult. They also estimated the O2 and CO2
tension gradients across the placenta between the maternal and fetal blood (Roos and
Romijn 1937, 1938). During the World War II German occupation of Holland, Roos,
who was Professor of Veterinary Physiology, was arrested and sent to the concentra-
tion camp at Mauthausen, where he was executed “for trying to escape” (Coppenhagen
and Liegburg 2000). Later, Romijn became Professor of Veterinary Physiology and
Dean at the College of Veterinary Medicine at Utrecht. An authority in the field of
embryonic metabolism and thermoregulation in poultry, he was the recipient of
many awards.
Several years following the studies of these early workers, the neonatologist,
Clement Smith (Fig. 2.5b) and colleagues of Harvard University presented a detailed
study of human oxyhemoglobin saturation curves, giving P50 values of about 23 and
28 Torr at pH 7.40 and Pco2 40 Torr for fetal and maternal blood, respectively. These
workers also showed that, following birth the P50 value increased to that of the
normal adult by 1 month of life (Darling et al. 1941). Later investigators would
demonstrate that although in most species studied the oxyhemoglobin dissociation
2.4 Nicholson J. Eastman, Huggett, and Others of the 1930s to 1950s 17

curve of the fetus lies to the left of that of the mother, this is not universally the case,
with the half-saturation partial pressure varying from 0 to almost 20 Torr. In addi-
tion, the mechanisms responsible for the shift in the fetal dissociation curve have
been shown to differ among species (Longo 1987). Importantly, Smith and a col-
league attempted to address the issue of the O2 needs of the newborn infant, includ-
ing those born prematurely. They noted, “the oxygen economy in the fetus at the
moment of birth cannot be taken as representative of the physiologic status which
has obtained until that time in fetal life, although there has been some tendency to
accept such an assumption” (Smith and Kaplan 1942, p. 844).
In 1930, Huggett accepted a Lectureship in Physiology and Reader in
Pharmacology at the University of Leeds, where he remained for 5 years. In addi-
tion to continuing the studies of placental glycogen and fetal respiratory reflexes he
had initiated at St. Thomas’ (Huggett 1929, 1930), while at Leeds Huggett collabo-
rated with the chemist Frederick Maurice Rowe (1891–1946) on the anticoagulant
properties of azo dyes. Of importance to the field of developmental physiology, in
1932 Huggett visited the laboratory of Joseph Barcroft at Cambridge University, to
consult on the measurement of blood volume (Elliot et al. 1934) as well as the use
of bisazo dyes. The following year Huggett acknowledged the “personal aid” of
Joseph Barcroft in his determination of fetal lamb blood volume. Regarding this
collaboration, Huggett noted, “… I should like to record my thanks to Mr. J Barcroft
for much advice, for facilities while at Cambridge, and for the loan of apparatus in
London, enabling me to carry out this work” (Elliot et al. 1934, p. 171). It was in
conjunction with this visit that Barcroft, at that time a world authority in hemoglo-
bin and the respiratory function of the blood (Barcroft 1914, 1926a, 1934a), became
interested in the developing fetus and its oxygenation (Barcroft 1933, 1934b;
Roughton 1948). Barcroft also credited Huggett’s work on the major differences in
O2 and CO2 in fetal and maternal blood as stimulating his interest in this field
(Barcroft 1946, p. 166).
In 1935, Huggett returned to London, as Chair of Physiology of St. Mary’s
Hospital Medical School, remaining there until his retirement in 1964. At St. Mary’s,
he carried a heavy teaching load with only one other full-time faculty member.
It was not until the end of World War II (1945) that Huggett was able to resume
fetal research in a major way, with the collaboration of D. Pauline Alexander,
Hubert G. Britton, Archibald David Mant Greenfield (1917–2005), and D.A.
Nixon. A problem that attracted Huggett’s interest was that of fetal nutrition and
carbohydrate metabolism (Huggett 1941, 1944a, b, 1946), and their relation to pla-
cental function (Huggett 1941). He confirmed the relative constancy of placental
glycogen under a variety of conditions (Davy and Huggett 1934), and measured the
levels of glucose and fructose in blood of the fetus, as well as that of amniotic and
allantoic fluids (Huggett et al. 1949, 1951). Huggett also was one of the first inves-
tigators to use 14C-labeled carbohydrates (glucose) in the study of transplacental
fluxes (Alexander et al. 1955a, b; Huggett and Morrison 1955). In addition to the
goat, Huggett investigated a variety of placental and fetal functions in the sheep,
rabbit, rat, and mouse (Frazer and Huggett 1970; Huggett and Morrison 1955;
Huggett et al. 1949). For instance, by infusing labeled glucose or fructose into the
18 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

blood of either the pregnant ewe or her lamb, he showed that fructose in fetal blood
is derived from glucose. He also demonstrated that while glucose freely crossed the
placenta from both mother to fetus and vice versa, fructose crosses only from
mother to fetus, and is formed in the placenta (Huggett et al. 1951; Nixon et al.
1966). In a number of species Huggett also contributed to an understanding of the
determinants of fetal growth in relation to gestational length (Huggett 1956, 1959;
Huggett and Widdas 1951). One of Huggett’s coworkers developed a plethys-
mograph to use on the umbilical cord (Greenfield 1949), in which the umbilical
venous outflow could be obstructed without impeding arterial input (Cooper and
Greenfield 1949). By use of this plethysmograph, Huggett and his collaborators
made the first measurements of umbilical blood flow in sheep (Cooper et al. 1949),
and compared this with that of the guinea pig (Greenfield et al. 1951a, b). To study
placental metabolism of carbohydrates, Huggett and coworkers also developed
techniques to perfuse the placenta with both recirculation (Huggett et al. 1951) and
non-recirculation (Alexander et al. 1955a, b).
During a sabbatical year 1953–1954, Huggett worked with Samuel R.M.
Reynolds at the Department of Embryology of the Carnegie Institution of
Washington, located in Baltimore, MD. Here, he explored aspects of the transmis-
sion of glucose across the placenta in monkeys, as well as in women who were to
undergo cesarean section. It was at this time that Reynolds and Huggett developed
the method of cannulating the interplacental artery of the rhesus monkey, Macaca
mulatta. By darkening the operating room and illuminating the uterus with a bright
pocket flashlight, they visualized the “intraplacental vessels… as straight or slightly
curving vessels with no branching whatsoever” (Huggett 1954a, b; Reynolds 1978;
Reynolds et al. 1954). Following these studies, Reynolds went on to make a number
of contributions to developmental physiology (Reynolds 1955, 1959, 1965;
Reynolds and Paul 1958).
Working with several other investigators, in 1954 Reynolds organized a weeklong
special symposium “The Mammalian Fetus: Physiological Aspects of Development,”
which he chaired. Held at Cold Spring Harbor, on Long Island, NY, over 125 scien-
tists from the USA and Europe participated. These included anatomists, embryolo-
gists, physiologists, biochemists, geneticists, and clinicians. The aim of this
conference was to evaluate the then current state of knowledge about almost every
aspect of the mammalian embryo and fetus, particularly that of the human. Following
consideration of some aspects of embryonic development, the group concentrated
on what was known and what was not known about a number of aspects of fetal
development, metabolism, and physiology (Demerec 1954). The proceedings of
this symposium were published as volume XIX of the Cold Spring Harbor Symposia
on Quantitative Biology, 1954. Uniquely, this Symposium was not only the first
such meeting devoted to fetal physiology, but was attended by almost all of the
international investigators in the field. In addition to formal presentations, lively
discussions followed. Many have agreed that this Conference was a seminal deter-
minant in furthering interest in, and development of, the field of fetal and neonatal
physiology. Following this symposium, Huggett summarized much of his work on
2.4 Nicholson J. Eastman, Huggett, and Others of the 1930s to 1950s 19

placental sugar transport in the first of the Josiah Macy Foundation conferences on
Gestation (Huggett 1955). A decade later Geoffrey Dawes recalled “The meeting at
Cold Spring Harbor in 1954 marked an epoch in the development of studies on the
fetus and newborn. That meeting generated an excitement and inspiration that all
who attended will remember” (Dawes 1966, p. 74). Still later Dawes stated, “This
first post-war international meeting was a turning point for many of us younger
physiologists who were fortunate enough to be invited, and who there met all those
who had already made important contributions to the subject” (Dawes 1980, p. 4).
Through his studies of fetal homeostasis, oxygenation, glucose metabolism, and
other subjects, Huggett’s influence continues to stimulate investigative work in
these vital areas. Huggett received a number of awards and honors including an
honorary Ph.D. (1925) and D.Sc. (1930) conferred by the University of London. He
served as Still Memorial Lecturer of the British Paediatric Association (1951),
De Lee Lecturer of the University of Chicago (1953), Claude Bernard Lecturer at
the Sorbonne in Paris (1955), and Purser Lecturer at Trinity College, Dublin (1956).
He was elected a Fellow of the Royal Society (1958), a Fellow of the Royal College
of Obstetricians and Gynaecologists (1960), and a Fellow of the Royal Society of
Edinburgh (1965).
Later, Dawes would reminisce that “The modern period of fetal physiology
begins with the work of Huggett who during the 1920’s [sic] showed that it was
possible to undertake acute experimental observations in fetal goats” (Dawes 1980,
p. 4). In his biographical memoir of Huggett, Francis William Rogers Brambell
(1901–1970) observed,
There can be no doubt that Barcroft and Huggett, the one wholly and the other partly Irish,
working simultaneously but essentially independently and on different aspects of foetal
physiology, the one at Cambridge and the other in London, were largely responsible for the
revival of interest in this subject. The great advances in this field that have been made dur-
ing the last 40 years in this country, in the United States of America and in Europe can be
traced to the stimulus which their work provided. Huggett’s part in this revival has tended
to be overshadowed by that of Barcroft, who was far better placed for facilities and to attract
recruits to his school. Yet Huggett’s contribution, with the resources available to him, was
great, though the recognition he received during his lifetime was relatively meagre. His
paper in 1927 on foetal respiratory exchange in the goat was the starting-point of this
revival, though his major personal contribution was the long series of papers on the carbo-
hydrate metabolism of the placenta and foetus. He built up around himself at St. Mary’s a
notable school whose members are continuing to extend our knowledge of various aspects
of foetal life. His place in the history of foetal physiology is honourable and secure.
(Brambell 1970, pp. 359–360)

In a review of several aspects of the field, Robert Alexander McCance (1898–

1993), of Cambridge observed, “Perinatal physiology owes a great deal of debt to a
few people; Huggett was one, and his influence on the Physiological Department at
St. Mary’s Hospital shows it …. He introduced Joseph Barcroft to the experimental
possibilities of the ruminant and so set the stage for all the work which was subse-
quently to go on at Cambridge” (McCance 1977, p. 141). Regarding Huggett, David
James Mellor (Fig. 2.5c) of Massey University, Palmerston North, New Zealand
recalls,
20 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

Arthur, St George, Joseph, McCarthy Huggett … had as many letters after his family name as he
did in his given names before it! His qualifications began with FRS, Fellow of the Royal Society,
because he had been elected a Fellow on 20 March 1958. He was my first PhD supervisor and I
was his last PhD student because he died … 22 months after I started my PhD in Edinburgh in
September 1966. During those … months he shared some of his experiences with me.
He was probably the first person in the UK in the modern era to seriously investigate sheep
fetuses. In about 1927 … he had immersed the hindquarters of anaesthetized pregnant sheep in
warm saline baths and surgically exposed their uteruses [sic] and fetuses which he then observed
while they floated in the saline. He had long experience of fetal physiology … at the St Mary’s
Hospital Medical School in London. He retired from there in the mid-1960s to become consul-
tant physiologist at the Moredun Research Institute in Edinburgh, Scotland, where our paths
crossed in late 1966. Unfortunately, failing health and, sadly, intellectual capacity, limited the
academic benefits I could gain from his long experience in the area. However, he eventually
became convinced that I had, in fact, received the very extensive, and even for that time, unusual
training in experimental surgery of sheep and other mammals that I claimed to have done in
Australia during my … BSc Honours degree. A feature of the BSc undergraduate major in
Physiology at New England University in the 1960s was the duplication of numerous anaesthe-
tised animal models which were used to demonstrate cardiovascular, neurological and other
principles established previously by the then giants in the discipline. Also, recovery surgery,
including rumen fistulation, exteriorizing carotid arterial loops and adrenalectomy with replace-
ment therapy, for later detailed physiological study, were features in practical class in the third
year. Moreover, during my … Honours year in 1965 I studied 65 pregnant sheep using epidural
anaesthesia, and, as an adjunct, developed an isolated uterus preparation supported by a not very
effective heart-lung device which I designed. As a result Huggett approached the UK Home
Office on my behalf to have them allocate to me direct copies of all of his experimental
Certificates, linked to his Home Office License, which allowed a very wide range of investigative
procedures to be conducted on mammalian fetuses. Having accumulated these Certificates since
1927, this action was immensely helpful during my subsequent fetal researches in Edinburgh.
After I had finished my PhD in 1969, I was appointed as Head of the Physiology
Department at the Moredun Research Institute to replace Prof Huggett, but not, I hasten to
add, on his salary! I then had the astounding good fortune to convince the Director and the
government department with oversight of the Institute to fund a purpose-built fetal physiol-
ogy research unit. It was opened in 1971. The unit had two large sheep houses and three
smaller rooms containing individual pens for 54 pregnant sheep, a surgery, recovery room
and feed preparation room, and, outside, a large covered yard for holding groups of ani-
mals. This unit enabled me to run up to 28 chronically catheterised ewes at any one time.
The additional pens meant that other ewes could be adapted to the indoor conditions,
including the diet, and could be tamed and trained for 6–8 weeks prior to uterine surgery, a
practice that was routine in the unit from the outset. The construction and staffing of this
unit mark the genesis of the Perinatal Studies Group at Moredun which I led until my
departure for New Zealand in 1988. Our remit was to undertake physiological investiga-
tions into the causes and prevention of neonatal mortality in lambs.
(Letter from DJM to LDL, 13 July 2009)

Some regard Huggett’s most important contribution to science, as that of mentor-

ing Wilfred Faraday Widdas (1916–2008). Following his service as a Medical Officer
in the Royal Army Corps during World War II, Widdas completed his doctorate in
physiology under Huggett at St. Mary’s Hospital Medical School. With considerable
facility in mathematics, his forte was to attempt to explain biologic phenomena in the
physical chemical terms of kinetics and in making quantitative predictions. In this
regard, Widdas contributed to a number of areas of placental and fetal physiology. For
instance, in terms of placental glucose transfer he calculated that facilitated rather
than passive diffusion was required to explain glucose flux rates (Widdas 1952).
2.5 Joseph Barcroft and a Widening of Interest in Physiology of the Fetus 21

Following his move to Chair the Department of Physiology, Bedford College,

University of London, Widdas pursued the studies of carrier-mediated membrane
transfer, including that which cannot increase in response to further increase in con-
centration gradient, now known as “saturation kinetics” (Boyd 2005). In particular,
his studies helped to elucidate flux across the erythrocyte membrane under different
circumstances (Sen and Widdas 1962a, b). Widdas also emphasized the importance
of carrier mechanisms for sugars, amino acids, and other nutrients, and the precise
regulation required for growth and development of the various fetal tissues, placenta,
and amniotic fluid (Widdas 1961). Later, he expanded upon these mechanisms
(Widdas 1988). Some have suggested that genes from his nineteenth century for-
bearer, the physicist and chemist Michael Faraday (1791–1867), had a valuable influ-
ence on his life (Boyd 2005). In addition to his scientific contributions per se, Widdas
served on and chaired the editorial board of The Journal of Physiology.

2.5 Joseph Barcroft and a Widening of Interest

in Physiology of the Fetus

Prior to the fourth decade of the twentieth century there was little general interest in
the physiology of the fetus or newborn per se. Hitherto, the subject comprised of mis-
cellany of anatomic morphology, and comparative anatomy, histology, embryology,
and the occasional bit of biochemistry. A seminal figure in respiratory physiology of
the first half of the century was Joseph Barcroft (later Sir Joseph) (Fig 2.3a, c) of
Cambridge University. Of Quaker heritage, he grew up in Ulster, Northern Ireland to
which his family had emigrated. In 1888 at age 16, because of his interest in science,
Barcroft was sent to Leys School, Cambridge; in 1896 he graduated from King’s
College. At Cambridge he had been president of the University Natural Science Club,
the membership of which during its first 100 years included ten future Nobel Laureates
(Pepys 1972). Following graduation, he joined the Physiological Laboratory founded
and directed by Michael Foster (later Sir Michael; 1836–1907). During these years
and the following several decades, Cambridge was a virtual hotbed of scientific talent.
Barcroft’s early work considered oxygen consumption of the salivary gland and the
manner in which this increased in response to nerve stimulation, demonstrating that
oxygen consumption continued even after the flow of saliva stopped (Barcroft 1900a,
b, c, 1901). These studies lead to the concept of oxygen “debt” in muscle and other
tissues. During this period, increasingly Barcroft became fascinated by tissue oxygen
metabolism and respiratory blood gases. In the course of these studies, he developed
the differential blood gas manometer, and the tonometer for equilibrating blood with
gas mixtures, tools he employed to characterize the properties of hemoglobin (Barcroft
1899, 1900a, b, 1908; Barcroft and Haldane 1902; Barcroft and Nagahashi 1921;
Barcroft and Roberts 1910). In his 1914 The Respiratory Function of the Blood,
Barcroft summarized his research over the previous decade and a half (Barcroft 1914;
second edition, 1926). Following World War I, Barcroft extended his studies of high
altitude physiology and the mechanisms by which the body acclimatizes to long-term
22 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

Fig. 2.3 (a) Sir Joseph Barcroft (1872–1947). (b) Barcroft Laboratory (ca. 1940). (c) Sir Joseph
lecturing (1947). (d) Title page (1946)

hypoxia (Barcroft et al. 1931). With his great interest in hypoxia, he studied blood
storage in the spleen, and the relation to blood volume (Barcroft 1926b, c; Barcroft et al.
1925). Based on his 1929 Edward Kellogg Dunham (1860–1922) lectures at Harvard
University, in 1934 Barcroft published Features in the Architecture of Physiological
Function (Barcroft 1934a). Of this work, Schack August Steenberg Krogh (1874–1949)
stated it to be a volume “… which gives an integration of physiology of such a kind that
it ought be read by everyone who is going into experimental work in physiology. It gives
the general ideas which cannot be obtained from any other book in existence” (see
Franklin 1953, p. 213).
2.5 Joseph Barcroft and a Widening of Interest in Physiology of the Fetus 23

In 1928, in his studies of blood volume, somewhat serendipitously Barcroft

discovered that the spleen of a pregnant dog was quite contracted (Barcroft and
Stephens 1928). This raised in his mind the question of the quantity of blood required
by the uterus during pregnancy. He measured the amount, finding it unusually large,
even during the early stages of pregnancy (Barcroft 1932; Barcroft and Rothschild
1932). Barcroft’s initial study involving an aspect of reproduction was on uterover-
din, the green pigment in the placenta of the dog and several other species (Lemberg
and Barcroft 1932; Lemberg et al. 1931). Shortly thereafter, Louis Barkhouse
Flexner (1902–1996), then of the Department of Anatomy at the Johns Hopkins
University, spent 2 years with Barcroft as a postdoctoral fellow. He then went on to
become a leader in placental exchange mechanisms and neuroscience (see below).
With Flexner, Barcroft performed his initial study in fetal physiology, measuring
cardiac output in the goat (Barcroft et al. 1934a) and fetal oxygenation in the rabbit
(Barcroft et al. 1934b). David J. Mellor recalled an incident in this regard,
Prof Huggett said that he had shown Sir Joseph Barcroft how to do his first Caesarian section
in sheep. He claimed, and I want to emphasize the words ‘he claimed’, that he anesthetized
a pregnant ewe, did a ventro-lateral abdominal incision, and just as he was moving viscera
aside in order to draw out the uterus, Barcroft … elbowed him to one side with words to the
effect, “I can take it from here Huggett!”, whereupon he promptly incised the rumen!
(Letter from DJM to LDL, 13 July 2009)

In an historical perspective, Barron noted that Barcroft’s interest in the course of

blood flow through the fetal heart and the timing of the closure of the ductus arterio-
sus arose from his studies on the oxygen environment of the fetal brain and the
dramatic changes at the time of birth with arterialization of blood in the newborn
lungs (Barcroft 1938; Barron 1979). With his background in studies of blood oxygen
capacity and oxyhemoglobin saturation curves, Barcroft compared the O2 content of
umbilical arterial and venous blood with that of the carotid artery in lambs delivered
by cesarean section. He concluded that the crossing of the superior and inferior vena
caval streams in the heart was essentially complete, and that the quantity of blood
ejected from the right ventricle via the ductus arteriosus equaled that volume in the
left ventricle that flowed through the foramen ovale (Barcroft 1935a). Barcroft also
recorded that during pregnancy uterine venous [HbO2] declined, reaching such low
levels that it seemed impossible to maintain a normal state of fetal oxygenation
(Barcroft 1935a, b, c, d; Barcroft et al. 1940b). The importance of these problems
launched him on a full investigation of oxygenation of the fetus.
An example of the manner in which Barcroft could synthesize data, incorporating
and expanding upon the work of others, is illustrated by his determination of the
fetal and maternal oxyhemoglobin saturation curves. A master in analyzing blood
and its oxygen affinity, Barcroft stressed the essential nature of hemoglobin and its
physical and chemical environment in determining blood O2 binding characteristics.
As noted above, Huggett had reported the fetal blood oxygen affinity to be signifi-
cantly different from that of the adult (although showing it to be less rather than
greater, e.g., P50 ~40 Torr) (Huggett 1927). With his great interest in this topic, using
blood at constant conditions (38 °C, Pco2 ~50 Torr), Barcroft and colleagues
24 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

reported the correct curves for the newborn goat and its mother (P50 = 30 Torr and
37 Torr, respectively), and also compared these at several times from week to week
as the fetus matured (Barcroft et al. 1934a; see Windle 1940, pp. 64ff). In a subse-
quent study, Barcroft and colleagues compared [HbO2] and O2 capacity in fetal
sheep blood from 63 to 145 days post conception (dpc), reporting on apparent peak
in [HbO2] of ~70 % at ~100 days, decreasing from that value until term (145 dpc)
(Barcroft et al. 1940a, b). This with other studies (Barcroft 1941, 1942, 1943)
contributed to his idea that the “newborn’s first breath was the fetus’ dying gasp.”
In his Researches on Pre-natal Life, Barcroft reviewed in extenso the several studies
to that time, and the many factors to consider in respect to oxyhemoglobin relation-
ships in the fetus and mother of humans, as well as that of other species that had
been studied (Barcroft 1946).
Fortuitously, in the summer of 1934 Barcroft met Donald Henry Barron
(1905–1993). At that time “J.B.” or “Jo,” as he was known by friends, headed one
of the most spacious and well-equipped physiology departments in the UK. Barron,
on a Fellowship of the National Research Council, USA, had spent 6 months in
Berne, Switzerland, and then moved to Cambridge University to work in the labora-
tory of Edgar Douglas Adrian (First Baron, later Lord Adrian; 1889–1977) and
Bryan Harold Adrian Cabot Matthews (later Sir Bryan; 1906–1986) on some aspects
of neurophysiology, including spinal cord action potentials (Barron and Matthews
1935). In a chance conversation at afternoon tea, upon learning that Barcroft had
purchased 50 ewes for his studies, Barron inquired as whether he proposed to study
the functional development of the mammalian nervous system. Admitting that he
knew nothing about this topic, Barcroft asked Barron to edify him on the subject.
After learning of the little that was known, and questions regarding the controversy
as to the applicability of findings in the nervous system of the mole salamander
Ambystomaidae to mammals, Barcroft invited Barron to join him in studying some
aspects of its functional development. For these studies, they would use the sheep as
an experimental “model”.
In the meantime, to support Barron and their joint research for a year, Barcroft
obtained a grant from the Rockefeller Foundation. By use of the technique devel-
oped by Huggett, of performing a cesarean section in a warm saline bath to maintain
the placental circulation, in November 1934, Barcroft and Barron commenced their
studies on a sheep fetus at 46 days gestation. Fortunately, for the future of the project
and the field of fetal physiology, the fetus showed considerable activity, “respiring”
spontaneously with rhythmic diaphragmatic movements (Barcroft et al. 1936).
In the spring of 1935, shortly before he was made Knight Commander of the British
Empire (KBE), Barcroft invited American investigators from the opposing schools
of thought regarding neural development to collaborate with him on this line of
investigation. Those were William Frederick Windle (1898–1985) from New York
University, and also a member of George Ellett Coghill’s (1872–1941) (see below)
department at the Wistar Institute of Anatomy and Biology, Philadelphia, PA, the
latter of whom declined the invitation. In the winter of 1935–1936, Barcroft, Barron,
and Windle attempted to determine the extent to which the first movements by the
fetus represented a response to local reflexes versus mass movements. Although the
2.5 Joseph Barcroft and a Widening of Interest in Physiology of the Fetus 25

Fig. 2.4 (a) Alfred Ernest Barclay (1877–1949). (b) Title page (1944)

group did not agree on the interpretation of their findings, they demonstrated that
these movements appeared before the central nervous system was fully functional
(Barcroft et al. 1936; Barcroft and Barron 1936, 1937, 1939).
Barcroft’s studies, demonstrating the importance of the ductus arteriosus being
patent in the fetus but closing in the newborn, raised the question as to when and by
what mechanism this occurs. A serendipitous and fateful event at the March 1937
meeting of the Physiological Society in London, significantly influenced the course
of fetal physiology. A film made by Barcroft and Barron, “Experimental ‘chronic’
lesions in the central nervous system of the sheep foetus” (Barcroft and Barron
1937), was shown immediately before one made by Kenneth James Franklin
(1897–1966) a fellow of Oriel College, Oxford, and a colleague, “X-ray cinemato-
graphic film of a dogs heart”. (Only the Barcroft and Barron abstract was published
in the Proceedings; Barcroft and Barron 1937). As recorded by Alfred Ernest
Barclay (1876–1949) (Fig. 2.4a) and colleagues, “This accidental juxtaposition of
the two films suggested to Barron the new line of attack” (Barclay et al. 1944, p. v).
Franklin, an authority on the physiology of veins and blood flow in the inferior vena
cava (see Franklin and Janker 1936; Franklin and McLachlin 1936a, b, c, d) with
Barclay, an Oxford radiologist, were using cineradiography to study a number of
aspects of the central circulation. Barron has recorded, “The clarity of his pictures
26 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

was impressive” (Barron 1979, p. 2). Following this meeting on the train returning
to Cambridge, Barron suggested to Barcroft the potential value of cineradiology in
the study of the long-standing problem of the course of the fetal central circulation
and the timing of ductus closure. Following some correspondence between
Cambridge and Oxford, Barcroft with Barron developed a collaboration with
Franklin and Barclay that lasted from 1937 to 1940 (see Barclay et al. 1944, p. vi;
Dawes 1994). Barron has recorded some of the vicissitudes of these studies (Barron
1979). Particularly annoying was the fact that, without consultation with either
Barcroft or Barron, Barclay and Franklin published a detailed account of these
studies, in which they claimed that the ductus closed prior to clamping of the umbil-
ical cord or visualization of air in the trachea (Barclay et al. 1938). On later analy-
sis, this erroneous interpretation was shown to have resulted from the obscuring of
the ductus by pulmonary vessels (Barron 1979). Subsequent cineradiographs of the
pattern of circulation in the fetal heart and great vessels demonstrated closure of
the ductus arteriosus some time following birth. In these studies, they also compared
the central circulation in the fetus with that of the adult (Barclay et al. 1939).
In relation to this fiasco, Barron reminded readers that “The celebrated German
physiologist Carl Ludwig [(1816–1895)] is said to have remarked, ‘In science,
method is everything.’ In this study it was!” (Barron 1979, p. 3).
The question of the course of blood flow through the heart and great vessels of
the fetus had been of interest since earliest times. Among his voluminous writings,
Galen, the Greek physician to the gladiators and others, anatomist and philosopher
and who spent much of his life in Rome, gave the first account of the fetal heart.
He described both the foramen ovale and ductus arteriosus, including details of
their fate following birth. In addition, Galen commented upon the relatively small
flow of blood through the pulmonary vessels prior to the significant increase fol-
lowing the onset of respiration. Being unaware of the circulation of the blood, his
descriptions of the role of the blood and the paths by which it flowed in the great
vessels was rather disordered (see Galen 1914 and below). In his monumental
Exercitatio anatomica de motu cordis… [Anatomical studies of the motion of the
heart] of 1628, following his epochal description of the motions of the heart and
circulation of blood in the adult, William Harvey described the essence of blood
flow through the heart of the fetus. Because some of the ambiguous terminology
he used for the vessels and other structures, there was room for confused interpre-
tation. Despite Harvey’s description being essentially correct, three centuries
elapsed before the anatomical features and valid course of blood flow from the
superior and inferior vena cavae (SVC and IVC) through the right atrium, foramen
ovale, and on to the brain and other organs was established. Even at the com-
mencement of the nineteenth century, three major theories were espoused as to the
course of blood flow in the fetal heart following its transit from the superior and
inferior vena cavae.
The first of these theories was that of Raphaël-Bienvenu Sabatier (1732–1811),
a Parisian surgeon, who described blood entering the right atrium from the inferior
vena cava passing directly and without mixing with blood from the superior vena
cava, through the foramen ovale to the left atrium and ventricle, to be pumped into
2.5 Joseph Barcroft and a Widening of Interest in Physiology of the Fetus 27

the aorta, and then onto the brain and upper extremities (Sabatier 1791). This flow
of arterialized blood from the placenta to the upper body was believed to account for
the relatively more rapid growth of the head and brain, as compared to the hindquar-
ters. The second theory, that of Caspar Friedrich Wolff (1733–1794) placed the
orifice of the inferior vena cavae dorsally, between the two atria, with the IVC blood
splitting into two streams, each of which entered its respective atria, flowing then
into the respective ventricles, and on to the pulmonary artery and aorta, respectively
(Wolff 1778). This view, in essence also was held by Preyer (1885) and one of his
students (Ziegenspeck 1905). The third theory, was that of Harvey (and essentially
that of Galen), e.g., that blood from the SVC and IVC mix in the right atrium before
passing through the foramen ovale, then to the left atrium, left ventricle, and on to
the aorta. In his experiments in deer and other mammals, Harvey described the flow
of blood through the foramen ovale and it passing into the left atrium, and thence
into the left ventricle to be pumped into the aorta. “The right ventricle, [which]
receiving blood from its auricle, propels it through the pulmonary artery and its
continuation, … the ductus arteriosus, to the aorta…. In embryos, then, while the
lungs are as inert and motionless as though not present, Nature uses for transmitting
blood the two ventricles of the heart as if they were one” (Harvey 1928, p. 57).
At the beginning of the twentieth century, Augustus Grote Pohlman (1879–
1950), of Indiana University, reviewed the several theories of blood flow through
the fetal heart (Pohlman 1907, 1909). Noting the inadequacies of previous studies
in the nonliving animal, he conducted a series of experiments in fetal pigs obtained
at an abattoir. With a ligature passed around the heart at the atrioventricular groove,
by rapid occlusion of ventricular outflow at the end of atrial systole, he first deter-
mined that the right and left ventricles contained equal volumes of blood (values not
given). In a further study, by inserting capillary tubes into the ventricular lumen
and measuring the level to which the blood rose, Pohlman determined that at end-
diastole, the pressures in the two ventricles were equal. Then, following injection of
either natural or colored cornstarch granules suspended in saline into the SVC or
IVC, and counting the particles contained in blood sampled simultaneously from
the two ventricles, he concluded, in agreement with Harvey, that blood from the two
caval streams mixes thoroughly in the right atrium, prior to ventricular ejection.
The first to use such an experimental approach, Pohlman noted that in his studies the
fetus was contained in utero removed from the sow some minutes previously, and
that the thoracic operative interference required for the experiments may have
affected the results (Pohlman 1907, 1909). Later, Pohlman compared the embryonic
circulation in reptiles and birds with that of the fetal circulation of several mamma-
lian species. He noted the presence of the foramen ovale in those animals with a
four-chambered heart, and in warm-blooded mammals the requirement following
birth, with lung expansion and closure of the ductus venosus to ensure balanced
pulmonary and systemic circulations (Pohlman 1924).
Following Huggett’s initial study on O2 and CO2 in fetal blood, Howard Butters
Kellogg (1898–1988) of Northwestern University also examined the course of
blood flow from the superior and inferior vena cavae through the heart. As in the
experiments of Pohlman, he injected suspensions of either India Ink or 10 %
28 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

cornstarch into the umbilical vein or the external jugular vein of ~125 pig fetuses of
various ages. Kellogg observed simultaneous blanching or blackening of both ven-
tricular myocardia (Kellogg 1928). He noted that this study confirmed in the fetus
that blood from the superior and inferior vena cavae mix. Kellogg stated, “These
observations, while not primarily of a quantitative value, constitute definite evi-
dence proving beyond a doubt that the two caval streams do mingle in the right
atrium, whereupon both ventricles receive mixed arteriovenous blood. They are
especially important, because they involve no subsequent disturbances of the heart”
(Kellogg 1928, p. 454). In five dog fetuses, Kellogg further established these find-
ings following umbilical vein injection. In a semiquantitative study in which he
counted the starch granules in blood of the ventricles, he calculated that the left
ventricle received 16 % more blood from the IVC than did the right (Kellogg 1928)
(this may have been within experimental error, however). In a subsequent study, he
used the Van Slyke micromethod to quantify oxygen and CO2 content of blood from
both ventricles, showing them to be of similar magnitude. Again, this supported the
concept of mixing of the two caval streams in the right atrium (Kellogg 1930).
Although one may criticize some aspects of Kellogg’s methods, his contributions
were to deliver the fetuses by cesarean section while maintaining the uterine and
umbilical circulations, preventing fetal respiration by placing the amniotic mem-
branes over the fetal head, and in recognizing the value of quantitative blood gas
analysis for the study of questions regarding the fetal circulation. These methods
would prove of great value to Barcroft and his successors.
In the decade following these studies, Barcroft published a number of contributions
on fetal respiration, blood volume, and circulation (Barcroft et al. 1939a, b, 1940a, b).
The onset of World War II, however, terminated these productive collaborations.
During the war, Barcroft chaired the UK Food Investigation Board and worked to
found Britain’s Nutrition Society (Franklin 1953). In the early 1940s, Maureen Young
(Fig. 2.5a), later of St. Thomas Hospital Medical School, worked with Sir Joseph. She
has written,
I assisted “Jo” … in a study at Cambridge towards the end of WWII. I had been at the South
West London Blood Transfusion Unit for two exciting years when Nora Edkins and
Margaret Murray persuaded me to join them in the Department of Physiology at Bedford
College, Bedford, as a Demonstrator, to “keep the lamp of learning burning”. They had
been evacuated to Cambridge where our teaching took place in the theatres and lab when
free of their own students. Jo, already in his early 80s, was still working. We all were invited
to ‘assist’ at his experiments on foetal sheep, which at this time was delivered into a huge
saline bath! At the end of the day, we all were rewarded with a most welcome lamb joint to
take home for Sunday lunch.
One day Jo stopped me in the corridor and said that he had asked Dr. Edkins if I might
give him a little of my time to help him with a small study. He said, “my fingers and eyes
are no longer organs of precision!” The fetuses of pregnant rabbits treated with progester-
one became post mature and died ‘in utero’. Jo wanted to know if they had outstripped their
placental oxygen supply and needed blood samples from the fetuses. He found an animal
table on which he could work in his small office and asked Adaire—another delightful
‘retired’ gentleman in the lab—to teach me how to use the original van Slyke apparatus to
measure the blood oxygen content. It was a splendid experience. Taking blood from the
carotid artery of the rabbit foetus did not prove a problem, and gave me courage to use the
perfused placental preparation later on in my career. The fetuses also provided another
2.5 Joseph Barcroft and a Widening of Interest in Physiology of the Fetus 29

Fig. 2.5 (a) Maureen Young. (b) Clement Andrew Smith (1901–1988). (c) David Mellor holding
lamb delivered following two months chronic catheterization (1971)

small observation, namely that the umbilical cord had a little sphincter only at its junction
with the abdomen. Jo found me cutting sections of this one day and said that it should be
published in Nature (Young 1953), and there it is!
With great charm and marvelous curiosity to the end of his life, Jo joins Widdowson and
McCance for creating the stimulus for our interest in and the great progress which has been
made in the subject of Perinatal Physiology worldwide during the last eighty years.
(Letter from MY to LDL, May 2012)

In 1944, Barclay, Franklin, and Marjorie Mabel Lucy Prichard collated their radio-
graphic studies in The foetal circulation and cardiovascular system and the changes
that they undergo at birth (Barclay et al. 1944) (Fig. 2.4b). The authors stated this to be
“… the gist of seven years’ radiographic, historical, and anatomical research upon
the foetal circulation and the cardiovascular system.” They observed that although
the work was too long and too detailed to appeal to the dilettante, “we believe…, that
the more serious student will find himself amply repaid for a few days careful perusal
of our account, in view of the great interest in the subject” (Barclay et al. 1944, p. viii).
Following a rather extensive historical introduction, in a dozen chapters the authors
presented a wide range of studies. Focused chiefly on the fetal lamb, they also included
30 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

comparative anatomical studies in a number of mammals including: bear, elephant,

goat, gorilla, hippopotamus, kangaroo, lion, tiger, and whale. The authors concluded
with a consideration of the central circulation in the human fetus and the changes at
birth (Barclay et al. 1944). They also presented the caveat that, although these studies
were the first of their kind, and thus historic, “… too much reliance should not be
placed upon isolated observations, and that schemata which are based solely upon post
mortem measurements of vascular channels, or which fail to take into account all the
foetal flows, may on occasion be grossly misleading.” The authors confessed that this
work represented only the beginning, Fassus me in multis, quae ad foetum spectant,
non mihi satisfacere [In abundance am I bundled, burdened, in regard to observing the
fetus, not to my satisfaction] (Barclay et al. 1944, p. 252). A decade later, similar stud-
ies with the use of radio-angiographic techniques were conducted in the human new-
born infant (Lind and Wegelius 1954).
During and following his studies on the fetus, Barcroft summarized his work to
date in several lectures and reviews. These included a 1933 address “The conditions of
foetal respiration” to the American Association for the Advancement of Science
(Barcroft 1933), the 1935 Croonian Lecture “Foetal respiration” to the Royal Society
(Barcroft 1935a), a major review “Fetal circulation and respiration” (Barcroft 1936),
the 1941 Cambridge University Linacre Lecture “Respiratory patterns at birth”
(Barcroft 1942), and the 1942 Finlayson Memorial Lecture at the Royal Faculty of
Physicians and Surgeons, Glasgow (Barcroft 1943). Each of these was notable in the
manner which Barcroft posed questions that were clear but provocative for their time.
These surveys laid the groundwork for Barcroft’s collation of these, and studies with
Barron and other colleagues (see Barcroft and Kennedy 1939; Barcroft et al. 1939b),
into his last monograph, Researches in Pre-natal Life, Part I (Barcroft 1946) (Fig. 2.3d).
In the preface of this work, which he dedicated to Donald H. Barron “… to whom the
work… owes so much,” Barcroft stated,
This work partakes very much of the nature of a will—I hope not my last. In the days of
bombs it seemed to me only the due of the many who had given me encouragement and
support, not least the Rockefeller Foundation, that I should set down in some connected
form such information as I had accumulated concerning prenatal life; then, if the bomb
came my way, the information, for what it was worth, would remain. I say ‘in some con-
nected form’ because not the least interesting part of the work has been the fitting together
of individual items, dealt with in individual papers, into a picture from which a likeness of
the organism is commencing to emerge.
A will necessarily deals with the property of the testator at the moment at which that
will is made. Some of his projects have come to fruition with assets safely secured, some
may look promising, others may be doubtful, yet all must be dealt with. So, in this book, in
so far as it is the bequest of such knowledge as I possess, or think I possess, I have put down
all that is supported by experiment. There are cases, however, about which the last word has
not been said, nor the last experiment completed. These I have indicated for the benefit of
such as may wish to undertake future research.
As regards the scope of the book, it purports to deal primarily with researches in which
I have had a hand myself, and with observations by others germane to such, but it goes a
little further and includes work by colleagues which I have been privileged to see, and even
work carried out under the auspices of committees on which I have served. It does not pur-
port to treat on any extensive scale of work with which I have had no personal contact; to
2.5 Joseph Barcroft and a Widening of Interest in Physiology of the Fetus 31

take a single instance, the beautiful work carried out at Johns Hopkins University on the
initiation of the heart beat—would that I could claim connection with that, but no! I must
take up the pulse at the point at which I commenced to observe it.
The general aim, then of this book is to trace the development of function in the mam-
malian foetus, never losing sight of the fact that one day the call will come and the foetus
will be born. Not only has the foetus to develop a fundamental life which will suffice for
intra-uterine conditions, but at the same time it has to develop an economy which will with-
stand the shock of birth, and will suffice, nay more than suffice, for its new environment.
(Barcroft 1946, p. ix)

In 22 chapters, in each of which he clearly stated a specific question to be

explored, Barcroft reviewed in depth what was known regarding fetal physiology.
Early chapters consider aspects of the maternal and fetal placental vasculature and
nutrient exchange, determinants of fetal growth, fetal blood volume and oxygen
consumption. In Chapter V “The relative claims of the foetus and mother to avail-
able nutritive material,” Barcroft stressed the symbiotic relationship of fetus to
mother, at a time the fetus was considered a “parasite”. Applying the principle that
nutrient partition among organs was determined by the metabolic rate, he argued
that with its relatively high rate of metabolism, the fetus could compete with mater-
nal tissues. The latter two-thirds of Researches on Pre-natal Life summarize much
of Barcroft’s and Barron’s work that considered blood pressure and vascular
reflexes, fetal blood oxygen capacity and oxyhemoglobin saturation curves, the
central circulation with roles of the ductus venosus and ductus arteriosus, and the
onset of respiration at birth. Seven appendices included variations in respiratory
activity at birth, measurements of blood sugar, lipids, and the molecular weight of
sheep fetal hemoglobin. Also included were recently derived blood gas values
obtained by Barron, “… from the small arteries and veins going to and leaving a
cotyledon, and … therefore more fully representative of placental conditions,”
which suggested a significant decrease near-term (Barcroft 1946, p. 285). Barcroft
had intended to prepare a second volume, Part II, that would deal with both the
nervous system and metabolism. With his demise shortly following this publication,
this was not to be, however. It must be recalled that Barcroft was 62 when in 1934
he embarked upon his studies of fetal physiology, and upon which he worked for the
next decade and a half.
Publication of Barcroft’s Researches…, immediately following the end of World
War II, appeared at the beginning of what some call the “golden age” of medical
research. Governmental support for biomedical studies increased (see below), as did
increasing interest in biology, from cellular and subcellular mechanisms to organ
and systems function, and clinical care, including that for the mother and newborn
infant. With concomitant technological advances that allowed ever more detailed
determinations and studies, Barcroft’s volume had considerable impact, both in
terms of promoting basic research as well as translational and clinical medicine
(Anonymous 1947; Holmes 1970; Young 1992).
Following his death, Huggett wrote a tribute to Barcroft in which he cited
Researches on Pre-natal Life as “… a landmark in experimental physiology, a fitting
32 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

successor to Preyer’s volume [of 1885] on the physiology of the embryo in the last
century” (Huggett 1947/1948, p. 231). He continued,
Barcroft’s death marks the end of an era in the physiology of the foetus. If he had lived it
would have been extended no doubt, but he himself was moving it on to the next phase. This
era extends from the early work of Zuntz to the present date, and can be described as the
phase of observational physiology. In this phase has been accomplished for physiology
the necessary description of the main processes which occur. Previous to this period, physi-
ological knowledge of the embryo and foetus was largely based on anatomical knowledge
and inferences from this. After the introduction of the saline-bath technique in the twenties
of this century, physiological facts have accumulated rapidly—largely under the influence
of Barcroft’s drive, personality, and ability to see the essentials of a problem, to dissect it
into its component parts, and to inspire workers in the British Isles, in Europe and in
America to tackle the several aspects so exposed. Simultaneously there have been three
other lines of approach which are now converging in the new phase setting in. These are:
the genetic approach; the endocrinological approach arising out of the study of the oestrus
cycle and the development of the fertilized egg; and the obstetric approach arising out of the
study of the nutrition of the foetus and the physiology of pregnancy, a study which has itself
been fortified by the foetal work of the last twenty years. At the end of this phase we there-
fore have a fair knowledge of the physiological action of the foetus and placenta.
In the new phase we must look forward to a synthesis of all these lines of approach
directed to the study of the peculiarly foetal problems of how function is initiated in the
embryo and how it can be controlled. In fact, we may as a result be able to visualize the foetus
not merely as a passive individual whose growth or development is outside our control, but
as one whose care will be within our power as much as is an adult patient—so far as that is
the case. The modern applications of biophysics must come into the field of experiment, to
explain how the gene, the hormone, the vitamin, and the nutrient react with the mother
to produce the newborn.
(Huggett 1947/1948, p. 232)

In his obituary notice of Fellows of the Royal Society, the Cambridge biochemist-
physiologist Francis John Worsley Roughton (1899–1972) stated of Barcroft,
It has already been said of Barcroft that he had changed but little in the course of his long
life, but retained his youthful freshness of mind and sense of wonder right through till the
end of his days. This was due not only to his innate character, but also to his unique habits
of work and thought, which endeared him to, and inspired all those who met or worked with
him in his daily round. For others who never had that privilege, it is fortunate that he has
himself revealed in his permanent writings such vivid examples of the methods and spirit of
his research, and such a clear picture of his own personality, scientific and otherwise …. He
would be apt to choose a field which was not at the moment in the forefront of the battle, …
however slight his knowledge at the start (and he would be the first to admit it), he would
soon be asking shrewd questions and talking in telling fashion about the existing ideas and
conceptions of the subject. Then, by some process of intuition, which rarely seemed to fail
him, he would succeed in picking out new and salient points of attack which, for one reason
or another, had eluded his predecessors. Next he would gather round him one or more
younger colleagues and infect them with his own enthusiasm for the new venture. In their
company he would buckle to and, if need be, devise methods which were often simple …,
but would almost always be singularly effective in guiding him quickly to significant results.
Thus armed, he and his happy band would forthwith plunge into a series of exhilarating, if
sometimes laborious, experiments; these usually brought forth a copious crop of new and
often unexpected fruit in a surprisingly short space of time. Then ‘he would return to report
on what he had seen and done—talking in that simple, exciting and slightly breathless way
2.5 Joseph Barcroft and a Widening of Interest in Physiology of the Fetus 33

he had, making all he had discovered seem so self-evident, poking fun at himself and paying
generous tribute to his collaborators’. The results, once established to his satisfaction,
would then be prepared for final publication with an ease and a gusto which many scientists,
who find ‘writing up’ so irksome, might well envy.
(Roughton 1948, pp. 329–330)

A subsequent symposium devoted to the chemistry and physiology of hemoglobin

in Sir Joseph’s honor, includes tributes to him (Roughton and Kendrew 1949). Later,
the Cambridge anatomist, James Dixon Boyd (1907–1968), described Barcroft as,
… concerned always with first principles and taking details in his stride. I shall always
remember how he could put one back on the tracks again by pointing out how one’s appar-
ently bright thought transgressed one or other of the primary laws.
Personally, nevertheless, I shall always remember him with gratitude, with respect and
with real affection for his character and his characteristics. I have known other considerable
scientists … But I wonder if I shall ever meet one who was so honest, so without guile, so
concerned with the truth in the very best sense of this abstraction. And to this one must add
friendliness, concern for the welfare of colleagues and friends, and a deep sense of justice.
It always rather embarrassed me that he should be so grateful, so honestly and unaffectedly
grateful, for the very small services that on several occasions I was able to perform for him.
He was kind because that was his nature, not for ulterior motive or design.
And now we shall no longer sense this kindly response, this ready friendliness. And, I
can write it honestly and with conviction, something very cherished has gone from my life.
I shall remember him with respect, affection and thanks.
(Boyd, in Franklin 1953, pp. 342–343)

Probably of Norman origin, the early years of the Barcroft family, from the
“de Berecrofte” of the thirteenth century to the late eighteenth century have been
traced in the historical survey Barcroft of Barcroft (Barcroft 1960). Following the
outbreak of World War II, in 1940 Barron returned to the USA, and in 1943 joined
the Department of Physiology at Yale University, where he continued his studies on
the fetal circulation and the placental exchange of respiratory gases (Barron 1946,
1952). In a critical review of the changes in the central circulation from fetus to new-
born at the time of birth, Barron placed the entire field into perspective (Barron 1944).
In the mid-1950s Giacomo Meschia joined Barron in studying placental respira-
tory gas exchange (Meschia and Barron 1956), and fetal oxygenation at high alti-
tude (Meschia et al. 1961; Metcalfe et al. 1962a, b; Prystowsky et al. 1960). It was
in 1965, that Meschia, Barron, and coworkers first reported on the use of chronically
indwelling catheters for measurement in vivo of respiratory gas values in fetal blood
(Meschia et al. 1965); a technique that was to place study of the fetus in utero on a
firm physiologic basis (see below). Importantly, it was with these and related stud-
ies, and with the collaboration of several postdoctoral fellows and colleagues that
Barron established the field of fetal physiology in the USA.
Acknowledging the inspiration he received from, and debt to, Barcroft, Barron
recalled a number of aspects of Barcroft’s contributions to life (Barron 1973). In an
earlier essay, he had noted,
I loved Sir Joseph above all men. I loved him for his passionate devotion to the truth; for
his charity towards his fellow man in all walks of life; for his devotion to young men and a
host of other intangible qualities. To emulate him was and will remain my life’s purpose;
34 2 A Scientific Genealogy: Early Development of Fetal–Neonatal Research

I can conceive no higher purpose. I have written only of my personal indebtedness to Sir
Joseph. My countrymen owe to him the same coin. No one has contributed more gener-
ously to the physiological thought of this country than he. The host of students who went
through his laboratory, learned his methods and acquired new vistas are spread throughout
this country, and they recall with advantage the days and weeks they enjoyed as members
of his School. And there are those yet unborn who will catch the spark of his wisdom
through the thoughts he put to pen. Few have given so much; fewer there are who had so
much to give.
(Barron in Franklin 1953, pp. 339–340)

In his recollections of Barron, David J. Mellor stated,

I first met Donald Barron through Prof Huggett. He visited Huggett at the Moredun
Research Institute for one day in late 1967. I still recall the several hours I was able to spend
with them on that day. During the morning I asked Barron dozens of questions about fetal
physiology and was delighted by the opportunity to do so and his encouragement. In the
afternoon he then outlined details of his work on oestrogen stimulation and progesterone
inhibition of fetal respiratory and physical activity. He began this account with the question,
“Mellor, have you ever wondered why a colt does not get up and gallop around in the uterus,
but within hours of its birth it gallops around in the field?” I had to admit that I hadn’t!
But I immediately recognized that it was a most intriguing question. At the time I did not
appreciate how influential that question would be in directing me much later towards some
fruitful paths of physiological thinking, which, now 42 years after he asked me that ques-
tion, I am still exploring.
(Letter from DJM to LDL, 13 July 2009; also Mellor 2010, p. 94)

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Chapter 3
Oxford and the Development of Physiology,
with Notes on the Nuffield Institute for
Medical Research

3.1 William Harvey and Seventeenth Century Physiology

As background for appreciating the development of fetal and newborn physiology,

one might consider what undoubtedly are some of the earliest studies on the embryo
and fetus that can be classed as scientific. William Harvey (Fig. 3.1a) recorded that
it was in the early 1630s, shortly following publication of his monumental Exercitatio
anatomica de mortu cordis… (Harvey 1628) that, with the privilege and blessing of
King James I (1566–1625; King from 1603 to death) and King Charles I (Charles
Stuart; 1600–1649; King from 1625 to his death), and for both of whom Harvey
served as personal physician, Harvey studied various aspects of generation in deer
and other animals that resided at the King’s estate. In addition to providing deer and
other animals from the Royal preserve, his royal patrons supported Harvey’s experi-
ments. Of this patronage, Harvey wrote that daily he had an opportunity of dissect-
ing and studying the reproductive and genital organs. He also credits the King with
taking a great interest in his work, for instance, “… my Royal master (whose
Physitian I was, and who was himself much delighted in this kind of curiosity, being
many times pleased to be an eye-witness, and to assert my new inventions)” (Harvey
1653, p. 397). A Royalist, in anticipation of the civil war Harvey later accompanied
King Charles to Scotland, and following the Battle of Edgehill (23 October 1642)
the first major action of the Civil War, the Royal party settled and set up Court in
Oxford. Within several months, Harvey was appointed warden of Merton College.
Here, Harvey took advantage of the opportunity to resume studies of the develop-
ment of hen’s egg that he had commenced earlier. He conducted these studies in the
rooms of George Bathurst, an Anglican divine of Trinity College, who had a hen to
hatch eggs in his chamber which they opened day after day, “That we may the better
discover what the… incubation hath produced” (1653, p. 80). Relatively uninter-
rupted by the political upheavals that surrounded him, Harvey pursued his embryo-
logical studies. As an aside, it should be noted that during the civil war, the period

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 43
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_3, © American Physiological Society 2013
44 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

Fig. 3.1 (a) William Harvey (1578–1657). (b) Sir Henry Wentworth Acland (1815–1900).
(c) Radcliffe Observatory. (d) William Morris, Lord Nuffield (1877–1963)

of parliamentarian rule during the Interregnum, and continuing through the restora-
tion, as a Royalist stronghold, Oxford was fiercely loyal to the Crown.
It was not until a decade later that Harvey’s treatise on the generation of animals
and embryology Exercitationes de generatione animalium… [Anatomical exercita-
tions concerning the generation of living creatures…], was published. Then, it only
was because his friend, the physician and anatomist Sir George Ent (1604–1689),
prevailed upon Harvey to allow him to perform “… the meer office of a midwife:
producing into the light this noble Issue of His Brain…” committing it to the press.
In his “Dedicatory Epistle” Ent wrote,
3.1 William Harvey and Seventeenth Century Physiology 45

A Calmer welcome this choice Peice befall,

Which from fresh Extract hath deduced all,
And for belief, bids it no longer begg
That Cafter once and Pollux were an Egge
That both the Hen and Houswife are so matcht,
That her Son Born, is only her Son Hatcht;
That when her Teeming hopes have prosp’rous bin,
Yet to Conceive, is but to Lay within.
Experiment, and Truth both take thy part:
If thou canst scape the Women! there’s the Art.
Live Modern Wonder, and be read alone,
Thy Brain hath Issue, though thy Loins have none.
Let fraile Succession be the Vulgar care;
Great Generation’s selfe is now thy Heire
(Harvey 1653, pp. xviii–xix)

In this work Harvey rejected the prevailing doctrine of the preformation of the
fetus, and advanced the fundamental theory, radical for its time, of epigenesis (per
epigenesin), that all living beings derive from the ovum “by the gradual building up
and aggregation of its parts.” Harvey’s Exercitations de generatione…, the first
English edition of which appeared 2 years later (Harvey 1653), thus was a major
advance in the study of reproduction. Regarding his theory of epigenesis, Harvey
considered this work to be of greater scientific import than his epic discovery of the
circulation of the blood by the pumping action of the heart, as detailed in De motu
cardis… (Harvey 1628). In this work on reproduction, Harvey reported a wealth of
observations on many of its aspects in a wide variety of species. As representatives
of vivipara, his attention chiefly was devoted to the deer, while that for ovipara was
the domestic foul. For Harvey, all life develops from the egg. This principle has
been of crucial importance in the history of embryology, and is expressed on the
frontispiece of this work which depicts the supreme Roman god Jupiter [Jove]
opening an egg, inscribed with the fundamental dictum of embryology, ex ovo
omnia [from the egg everything]. From this egg, in addition to a small human figure,
liberated animals and insects fly; these include a bird, stag, fish, lizard, snake, grass-
hopper, butterfly, and spider. Although the phrase omne vivum ex ovo [all life origi-
nates from the egg] is often attributed to Harvey, he does not state this explicitly in
the text. Harvey speculated that humans and other mammals must reproduce through
the joining of an egg and sperm; no other theory being credible. By positing and
demonstrating for viviparous animals the same mechanism of reproduction as that
observed in oviparous animals, he thus initiated the search for the mammalian
ovum. It remained for Carl Ernst von Baer (1792–1876) to make this discovery a
century and a half later (Baer 1827; see below). Harvey maintained that Jovis omnia
plena [All things are full of Deity], so that in the chicken and all its functions and
actions the Digitus Dei [the Finger of God] or the god of nature, reveals himself
(1653, p. 310). Harvey also wrote a work, Medical Observations, a treatise believed
to have concerned midwifery. Unfortunately this work was destroyed, with others,
at the beginning of the Civil War in August 1642, when Harvey was at Nottingham
with King Charles I.
46 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

Celebrated for his monumental discovery of the circulation of the blood (Harvey
1628), Harvey was the first to adopt the scientific method for the solution of a biologi-
cal problem (Singer 1922). In fact, it was Harvey’s work on the function of the heart
and the circulation in general that led him to consider the circulation of the fetus and
its relation to that of the mother. To help grasp the significance of Harvey’s achieve-
ment, one must consider the traditional Galenic concept of the heart, blood vessels,
and their contents at this time. Briefly, this doctrine held that blood was formed in the
liver, the dynamic organ that provided vascular pulsations. The heart, in contrast, was
believed to be a fibrous sac that dilated or collapsed passively as a consequence of
the blood’s motion. In the liver, venous blood was mixed with an imaginary essence,
the “natural spirits” to become a vegetative fluid, the elixir of nourishment that the
veins distributed to the several bodily organs. Within the right side of the heart venous
blood was believed to seep through “pores” in the septum separating the two ventri-
cles, to mix on the left side with air to produce arterial blood. (Also at this time, most
workers believed that the heart consisted of only the two ventricular chambers, and
that the atria were but extensions of the veins joining the heart). Within the left
ventricle these fluids were imbued with a second essence, “vital spirits” or “pneuma”
that entered the lungs with respiration, and passed via the pulmonary vein to the left
ventricle, before being distributed to various organs. In the brain, “animal spirits”
were added to pass through the nerves. Interaction of the “vital” and “animal” spirits
was believed to provide movement, such as muscular activity. Rather than circulating,
the two varieties of blood were thought to surge as a tide back and forth in the veins
and arteries (Frank 1980; Singer 1922; Wright 2012).
In establishing the circulation of the blood as a closed circuit, rather than the
ebbing and flowing from the two sides of the heart in two independent systems of
arteries and veins, it was Harvey’s observation of the relatively slow heartbeats of
cold-blooded animals that convinced him that contraction, not relaxation, was the
heart’s active action. His determination of the heart’s output into the aorta, demon-
strated this to be many times greater than the liver could produce at one time, as was
held by established doctrine. In regard to the placental circulation, Harvey stated,
“the Extremities of the Umbilical vessels, are no way conjoined to the Uterine ves-
sels by an Anastomosis; nor do extract blood from them…” (1653, p. 439). By logic
based on his knowledge of the circulation, he held the maternal and fetal circula-
tions to be separate, each following in an opposite direction to the placenta by way
of the arteries and returning by the veins.
In his Exercitationes de generatione… Harvey raised another question of funda-
mental importance to developmental biology and life in utero, that of the placenta
serving as the lungs for the fetus.
… I shall propose this Probleme to the Learned; namely, How the Embryo doth subsist after
the seventh moneth in his Mothers womb when yet in case he were borne, he would instantly
breath: nay he could not continue one small hour without it? And yet remaining in the
womb, though he pass the ninth moneth, he lives, and is safe without the help of Respiration
… How commeth it to pass, that the Foetus being now borne … if he have but once attracted
the Aire unto his Lungs, he cannot afterwards live a minute without it, but dyeth instantly?
(Harvey 1953, pp. 482–483)
3.2 Other Early Oxford Physiologists 47

He also noted that the “Embryo is in no other manner sustained in the Uterus,
then [sic] the chicken in the Egge” (1651, p. 240; 1653, p. 440). Based on knowl-
edge that in utero the fetus grows and matures in the absence of air, and at the time
of delivery it dies if the umbilical cord is compressed and it fails to breathe, Harvey
postulated that substances absorbed by the umbilical cord stimulated organ develop-
ment, while the fetus received its main nourishment from the amniotic fluid.
Following Giulio Cesare Aranzi [Arantius] (1530–1589) in his De humano foetu
(Aranzi 1564), Harvey also referred to the placenta as the hepar uterinum [uterine
liver] and mamma uterina [uterine breasts]. Not until a decade later did Marcello
Malpighi (1628–1694) of the University of Pisa first describe the capillary bed con-
necting arteries and veins (Malpighi 1661), and made possible an understanding of
the full anatomical basis of regional circulation. Lacking this knowledge, Harvey
could not understand completely certain details of the circulatory system in either
the adult or the fetus. Perhaps, in part, a secret to Harvey’s success was that in his
London home, in addition to his “research chamber,” he had a “meditating apart-
ment” for contemplation. Several reviews have examined Harvey’s contribution in
extenso (Bylebyl 1972; Hutchison 1931; Keynes 1966; Meyer 1936; Wright 2012).
“Harvey’s question” regarding fetal survival in utero, as it came to be known,
aroused the interest of both philosophers and experimentalists. With no clear under-
standing of respiration or metabolism, however, and without knowledge of the exis-
tence of oxygen (the discovery of which did not occur until the following century),
Harvey could only speculate on this matter. Many details of the path to discovery of
placental respiratory gas exchange, made two centuries later by the young Swiss
obstetrician, Paul Zweifel (1876), have been given by Donald H. Barron (1978).

3.2 Other Early Oxford Physiologists

During the seventeenth century, Oxford, the “city of dreaming spires” became a
center for the advancement of science. A seminal figure in the advancement of
science was the English philosopher, statesman, jurist, and author Francis Bacon,
Baron Verulam and First Viscount St. Alban (1561–1626). As opposed to the deduc-
tive approach to questions of nature employed by Harvey and others in previous and
more contemporary times, Bacon championed an inductive methodology in scien-
tific inquiry, e.g., reasoning from the particular to the general. The “Baconian”
method demanded an evidence-based approach to axioms, general principles, and
laws of science. Serving the Crown in many capacities, including Attorney General
and Lord Chancellor, Bacon’s thesis was that the most certain path to truth and
knowledge of nature was gained by observation. This concept, innovative for its
time, was expressed in several works, The proficience and advancement of learning
(Bacon 1605), Novum organum (1620), and De augmentis scientarium (1623)
(Spedding et al. 1857–1859). In his unfinished The great instauration, published after
his death (Bacon 1854), Bacon expressed his further vision of a consortium or organi-
zation that would acquire knowledge from all over the world, and put it to practical use.
48 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

The essential feature of this scheme was that the growth of knowledge should be a
collective activity, with groups of investigators observing the details of natural phe-
nomena. Upon collection of these observations, another group of scholars and philoso-
phers would interpret the results, and formulate the laws of nature. Finally, a third
group of inventors and entrepreneurs would use these laws to advance human well-
being and wealth. Far ahead of his time, Bacon’s organizational schema resembles
some contemporary institutions of science and technology. Despite his never having
performed an experiment, implementation of Bacon’s philosophy of the inductive
method changed the course of science, and for several generations he served as a
symbol for the ideal in science (Hesse 1970; see below).
As early as the late fifteenth and early sixteenth centuries, the physician-scholar
Thomas Linacre (ca. 1460–1524), a graduate of the University of Padua (1496) and
founder of the Royal College of Physicians (1518), with the collaboration of several
like-minded Renaissance humanists, introduced at Oxford the teaching of Western
European medicine (Cawadias 1936). As important as Harvey’s discoveries were to
establish a point, it was Harvey’s rigorous insistence on the experimental method—
based on the testing of well thought out hypotheses and his own observations—that
were even more influential to the history of biomedical science and physiology.
Following Harvey in the mid-seventeenth century, a number of physiologists and
others worked at the several Oxford Colleges, emulating Harvey and contributing to
science (Frank 1980; Keynes 1953). These included Nathaniel Highmore (1613–
1685), in whose The history of generation… (1651a), referred to the newly devel-
oped microscope to study embryological development in the chick. Highmore also
published his textbook Corporis humani disquisito anatomica, which he dedicated
to Harvey (Highmore 1651b). Another medical scientist of this period was Walter
Charleton (1619–1707), whose Onomasticon zoicon, plerorumque animalium…
presents the English, Latin, and Greek names for all of the then known animals
(1668). Another of Harvey’s acquaintances, and in fact one of his patients during his
Oxford stay, was the chemist-physiologist Robert Boyle (1627–1691). Boyle is
known primarily for his Certain physiological essays (1661a), The sceptical chy-
mist (1661b), and A defense of the doctrine touching the spring and weight of the air
(1662, 1682), in which he demonstrated a portion of air to be essential to life, and
laid the groundwork for the physiology of respiration and the gas laws on the inter-
relations of pressure and volume. Another of the early Oxford physiologists was
Robert Hooke (1635–1703), publishing Micrographica, or some physiological
descriptions of minute bodies… (1665), a classic contribution to microscopy. He
also described an experiment of preserving animals alive by using a bellows to blow
air through their lungs, thereby demonstrating that respiration depends on an ade-
quate supply of fresh air (Hooke 1667).
A number of other seventeenth century British scientists contributed to the
unparalleled pace of scientific discovery. A leader of the Oxford medical scientists
of this period was Thomas Willis (1621–1675), a Royalist soldier during the Civil
War, following the Parliamentary Interregnum he had been rewarded the Sedleian
Professorship of Natural Philosophy. He used his position to embark on a bold and
innovative project, to map the brain, its blood supply, and its nerves, and to
3.3 Founding of the Royal Society 49

determine their function. In the course of this work, Willis published the most com-
plete account of the central nervous system to this time, in which he coined the term
“neurology,” Cerebri anatome: cui accessit nervorum… [the anatomy of the brain
with accessory nerves] (1664). Over the next 8 years, Willis took advantage of his
experimental studies and clinical observations to write Affectonum quae dicuntur
hystericae et hypochondriacae pathologie spasmodica vindicata… [Cerebral
Pathology] on seizure disorders (1671), and Two discourses concerning the soul of
brutes… on neurological and psychological disorders. Another associate was Walter
Needham (ca. 1631–1691), who published a seminal work in chemical embryology
Discquisitio anatomica de formatu fetu, in which he called the placenta the “uterine
lung” (Needham 1667). Still another was Willis’ junior medical partner, Richard
Lower (1631–1691), who among other contributions successfully performed a
blood transfusion, The method observed in transfusing the blood out of one live
animal into another (Lower 1665/1666). He also wrote a major work on the heart
describing its “scroll-like” musculature (Lower 1669). A century prior to the dis-
covery of oxygen, by injecting dark venous blood into the pulmonary artery of aer-
ated lungs, in his Tractatus de corde, Lower demonstrated that air caused the blood
to become bright red in the pulmonary vein. He also presented a creditable account
of the fetal circulation (Lower 1669). John Mayow (1643–1679), also of Oxford, in
his Tractatus quinque medico-physici (1674), first demonstrated that the skeletal
muscles produce “animal heat,” and stressed the requirement for the fetus to be sup-
plied with “nitro-aerial particles” (e.g., oxygen). The Oxford professor of anatomy
(and later professor of music), Sir William Petty (1623–1687), a pioneer demogra-
pher and biostatician, wrote Several essays on political arithmetic (1699). He also
was the first to take a census of the population in Ireland. Another notable Oxford
scientist of this era, and friend of Lower and Willis, was Christopher Wren (later Sir
Christopher; 1632–1723) who during his tenure as Savilian Professor of Astronomy,
participated in the dissection of brains of a number of mammals, including humans.
Wren also attempted to produce narcotic anesthesia by injecting opium, wine and
ale (separately) into veins of a dog by means of a quill and pig’s bladder (Little
1975). Wren went on to become one of Britain’s foremost architects, who, follow-
ing the great fire of 1666 contributed greatly to the rebuilding of London, including
St. Paul’s Cathedral, and a number of other sanctuaries and wondrous structures
(see Frank 1980).

3.3 Founding of the Royal Society

A critical factor in the evolution of physiology, during the seventeenth century in

Britain and several other of the countries of Europe with the virtual explosion in
artistic and scientific creativity, men interested in the new science met together for
experimentation and discourse. This was a period of unparalleled discovery, and
these periodic gatherings led to the organization of scientific societies and acade-
mies. In part, this was a consequence of the Renaissance in the arts, humanities, and
50 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

culture, and which for science had begun in Italy a century earlier. With the Galilean
(named for Galileo Galilei, 1564–1642) revolution, an unprecedented, almost
miraculous leap forward occurred in the art of inquiry and investigation. In Britain,
it was a group of “natural philosophers” of such an “invisible college,” that begin-
ning about the year 1645 met weekly for the purpose of “improving natural knowl-
edge.” In about 1648–1649, under the influence of several of those noted above, the
group removed its meetings from London to Oxford. This blossoming of intellec-
tual activity was abetted by the founding of the Oxford Regius Professorship of
Medicine (1546) by Henry VIII (1491–1547; King of England 1509 to death), the
establishment of the Bodleian Library (1602), and creation of a physic botanical
garden of herbs and other medicinal plants (1651). With the scientific contributions
of the worthies, these developments blazed the trail for the foundation in 1660 of the
Royal Society (this was founded at Gresham College the leading seat of learning in
London, not Oxford) by a dozen “ingenious and curious gentlemen” to form a
“College for the Promoting of Physico-Mathematical Experimental Learning,” and
to publish their discoveries in natural philosophy for all to share. These scholars
thus were following the teachings, but not the practice, of the philosopher of the
previous century, Francis Bacon, whose writings promoted this almost revolution-
ary concept. With the Restoration and the ascent of Charles II (1630–1685; King
1660–1685) to the throne, significant advances followed.
Founded initially as “A Society,” in 1662 royal patronage was granted with a
charter. Several factors were critical to this success. Following the Restoration,
there was a determination to maintain religion and science in separate spheres of
influence. “Free thinking” was tolerated more widely, and King Charles II had great
interest in natural philosophy. Most important to the Royal Society’s profound influ-
ence on science per se, and to its support by the Crown, the parliament, and the
people, was the Promethean figures who led out in this enterprise. Formation of the
Royal Society, which was to herald a scientific revolution in Great Britain, preceded
by only several years the outbreak of the great plague in London (1665–1666) (dur-
ing which bubonic plague was differentiated from typhus) and the Great Fire of
London (1666), both of which wreaked widespread devastation. The motto of the
Royal Society Nullius in verba [accept nothing on authority; take nobody’s word for
it] was suggested by John Evelyn (1620–1706). That is, if you have an idea, develop
a hypothesis, test it by experiment, prove it by demonstrating the extent to which it
is valid (see Acland 1890, p. 16; Hinshelwood 1960). In fact it was the polymath
Evelyn’s Sylva, or a discourse of forest-trees, and the preservation of timber in His
Majesty’s dominions (Evelyn 1664) that was the first official publication of the
newly founded Royal Society. As Thomas H. Huxley pointed out,
If these ideas be destined … to be more and more established … if the spirit be fated … to
extend itself into all departments of human thought and become co-extensive with the range
of knowledge, if as our race … discovers … that there is but one kind of knowledge, and but
one method of acquiring it; then we, … may justly feel it is our highest duty to recognize
the advisableness of improving natural knowledge, and so aid ourselves and our successors
in our course towards the noble goal which lies before mankind.
(Bibby 1967, p. 41)
3.4 The Oxford Medical School and Further Developments in Physiology 51

It was these men of the Royal Society, devoted to the free inquiry and science,
who, by their thought and emphasis on publication and peer review, initiated the
humane scholarship which helped to create the traditions of modern science and the
traditions of Oxford University. A distinguishing feature of the Society was the work
of its members in collecting botanical, animal, and mineral specimens from around
the world, mapping previously unknown lands, and recording observations from all
over the globe. Of critical importance, the core values of the Royal Society have
enduring relevance. As other national academies, it has promoted excellence in sci-
entific research. Engaging broadly in the needs of society, it has attempted to stimu-
late the public understanding of science and demonstrate a commitment to public
affairs. The Royal Society also has played a key role in helping political leaders to
understand scientific issues, and promoting scientific education in general. Publishing
papers in its Philosophical Transactions and Proceedings from scientists throughout
Europe, and supporting first-rate investigative work regardless of country of origin,
it helped to establish English as the language of science. Perhaps of most impor-
tance, this revolution, from asking “why” to answering “how,” flowered into the
Enlightenment, the political, cultural, scientific, and educational revolution that gave
rise to the modern West (see Bibby 1967; Bronfenbrenner 1938; Bryson and Turney
2010; Dolnick 2011; Gribbin 2005, 2007; Poynter 1970, p. 238; Robb-Smith 1966;
Weld 1848). Nonetheless, this is not to say that later during the eighteenth or early-
nineteenth centuries, experimental physiology flourished at Oxford or elsewhere in
Britain. In contrast to developments in France and Germany, it did not.

3.4 The Oxford Medical School and Further Developments

in Physiology

In considering the development of physiology at Oxford University, one also might

consider the “Medical School” as the focal point of this study. Some have objected to
this term, even referring to it as “A Lost Medical School” (Collier 1904, p. 221), as it
only in relative recent times that Oxford has offered a complete education in medicine.
As historian Frederick Noël Lawrence Poynter (1908–1979) has noted regarding med-
ical education in England, “… from the sixteenth century onwards, this [topic] has
been almost constantly a source of … criticism and dissatisfaction.” And regarding
both Oxford and Cambridge, Poynter concluded, “…Medicine was not highly regarded
or vigorously pursued as an academic training” (Poynter 1970, pp. 235–236).
In his review of Oxford medical education prior to 1850, Alastair Hamish
Tearloch Robb-Smith (1908–2000) quoted Sir James Paget (1814–1899),
If the reputation of a University is to be measured by the number of medical men it turns
out, it must be confessed that Oxford and Cambridge have fallen short of their duty, but if
the office of a University be rather to educate men with the capacity for pursuing any pro-
fession, and to maintain a high standard of knowledge in its medical graduates, then they
have no reason to fear criticism.
(Robb-Smith 1966, p. 52)
52 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

During the latter nineteenth and early twentieth centuries, advocates for a medi-
cal school at Oxford believed that without such, the University would be starved of
talent to conduct biomedical research, thereby being denied the opportunity to
become an intellectual center of medical progress. In opposition, others argued that
routine clinical instruction and practice would undermine fundamental research, and
break with tradition whereby the University devoted itself to advanced research and
the humanistic education of the future élite. Those with this view held that the fun-
damentals of natural science relevant to medicine should be maintained at Oxford,
with clinical training to be conducted at the London medical schools with their
wealth of the sick and infirm. Because of the fundamental concept of the University
as a whole, this issue was divisive and contested bitterly (Webster 1994). Thus, until
mid-twentieth century, following their first few years at Oxford, students would
transfer to one of the London hospitals to complete their education. Henry Wentworth
Acland (later Sir Henry; 1815–1900) (Fig. 3.1b) a major influence in the develop-
ment of medicine and medical education at Oxford, detailed in a letter to his friend
Dr. James Andrew (1831–1897) of London, important milestones in the development
of basic and clinical medical science at the University and attempted to justify the
great need for its providing complete professional education in medicine (Acland 1890).
Poynter has observed that at mid-nineteenth century the Royal Commission on
the University of Oxford had concluded, “Oxford has ceased altogether to be a
school of medicine. Those few persons who take medical degrees there, do so with
a view to the social considerations which these degrees give or the preferment in the
University for which they are needed but study their profession elsewhere” (Poynter
1970, p. 242). In 1845, however, Acland was appointed Dr. Lee’s Reader in Anatomy
(named for Matthew Lee (1695–1755)), at Christ Church College, and influenced
for the good the development of medical education. Acland recorded, that this was,
“… before I graduated in medicine” (Acland 1890, p. 93). Two years later (1847) he
was elected to the Royal Society. Shortly thereafter, he commenced a campaign to
develop a Natural Sciences department, which included the building of a Museum
for Natural History, which was to be the center for scientific investigation at the
University. “… In 1854, a Delegacy was appointed to obtain plans; however, the
progress of the selected structure was opposed at every stage, till the building was
completed in 1860” (Acland 1890, p. iii). Although funds for lighting the structure
and surrounding area was approved by only two votes of the convocation (oversight
committee), that “… for oiling and varnishing all the fine oak window frames of the
front being lost, they baked unoiled through the hot summer of 1859 or 1860”
(Acland 1890, p. iii). With passage of the Medical Act of 1858 and creation of the
General Council of Medical Education and Registration of the UK, Acland repre-
sented Oxford University. In addition to its role in defining the “qualified medical
practitioner,” the Council played a critical role in establishing criteria for, and stan-
dards of, medical education. In later years, the Council promoting the idea that
medical research and teaching be pursued together (Poynter 1958, 1966b; Thomson
1958). In addition to the Library from the Radcliffe Infirmary, collections collated
for the museum included the natural science collection from the Ashmolean
Museum, the Anatomical Museum in Christ Church College, and the Geological
3.4 The Oxford Medical School and Further Developments in Physiology 53

Museum in the Clarendon Building. Lecture rooms and a hall for scientific meetings
also were provided (Acland 1890, p. 19). In 1858, Acland was appointed Regius
Professor of Medicine and Litchfield Professor of Clinical Medicine, and the fol-
lowing year he was appointed to the Thomas Linacre Professorship of Anatomy and
Physiology.
In regard to Oxford’s role in medical education, Acland asked in the manner of
his friend the English writer, critic, and philanthropist John Ruskin (1819–1900)
from “Whence do we come? Where are we now? [and] Whither are we going?”
(Acland 1890, p. 9). Inspired by the vast anatomical and surgical collection of the
Hunterian Museum in London, Acland commenced gathering an “Anatomical and
Physiological” series of anatomical specimens and drawings, some of his dissec-
tions being brought from Edinburgh, and the Van der Kolk pathological collection
from the Netherlands. Also included was a laboratory for Comparative Pathology
and Microbiology. To various authorities, including members of Parliament, as
models of a University based medical education and scientific work to be developed
at Oxford, Acland held up the Universities in Germany, and the newly established
Johns Hopkins University and Hospital in Baltimore. Acland also stressed the
importance of Preventative Medicine and Public Health. Included as one of several
appendices, Acland made a special case for the advancement in the study of physi-
ology and pathology at Oxford, writing, “What is derivable for the philosophical
student of Biology as a branch of general culture, is a necessity for the student of the
healing art, as one of the corner-stones of his profession” (Acland 1890, p. 54).
Acland expressed the desire that the University should be made “a place of the most
perfect preparation that can be devised” for the study of medicine (Acland 1890, p.
22). He concluded his argument by enumerating the ideal “Character of the Student
of Medicine … such a man any of you may be; but you must begin by learning to
stand by the sick-bed, and make it your delight” (Acland 1890, p. 58).
In 1876, the Physiological Society was founded, its initial meeting being held in
the home of John Burdon-Sanderson (later Sir John; 1828–1905) of the University
College, London and an authority on muscle electrophysiology. While chiefly cen-
tered by scientists at the London schools, charter members from Oxford included
Edwin Ray Lankester (1847–1929) and Charles John Francis Yule (1848–1905)
(Sharpey-Schafer 1927b). Contrary to what one might expect, the Physiological
Society was not founded for purely scientific reasons. Rather, in Great Britain stud-
ies on practical physiology were paralleled by the emergence of vocal opposition to
the use of animals as experimental subjects. In 1875, a Royal Commission of Inquiry
into Vivisection was established, and recommended that all such studies be gov-
erned by an Act of Parliament, with investigators licensed by the Home Secretary.
Recognizing the need for researchers to have some influence on parliamentary pro-
posals that might unjustifiably interfere with scientific progress, in March 1876
Burdon Sanderson hosted a dinner for a dozen and a half physiologists. They formed
a committee, drafted a constitution, and several months later commenced to meet on
a regular basis. Initial meetings of this physiological Dining Club were devoted to
sociopolitical considerations. Not until 1880 did scientific presentations and dem-
onstrations become a part of the meetings (Sharpey-Schafer 1927a, b). In an update
54 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

of activities of the Physiological Society to 1976, William Frederick Bynum then of

University College, London has emphasized the manner in which the Society has
maintained close links to the evolution of physiology in Great Britain (Bynum 1976).
In 1883, Burdon-Sanderson left London to become Oxford’s first Waynflete
Professor of Physiology. His goal was to develop Oxford as a school of scientific
medicine. In part, this had been aided by the Oxford University Commission in 1877
mandating a commitment to experimental physiology with erection of a physiological
laboratory. Severe opposition to this proposal by antivivisectionists and others, and an
ad hominem campaign against Burdon-Sanderson, almost aborted this development.
In 1895, however, upon Acland’s retirement Burdon-Sanderson was appointed to suc-
ceed him as Regius Professor of Medicine. The following year, to strengthen the pro-
gram in medical education, the new Regius Professor pressed for establishing two
new departments, pathology and pharmacology. Within a year, William John Smith
Jerome (1839–1929) was appointed lecturer in Pharmacology and Materia Medica. In
1901, the new pathology laboratory opened, which also housed the department of
pharmacology. In his Presidential Address at the 1904 Oxford meeting of the British
Medical Association, William Collier (1856–1935), physician at the Radcliffe
Infirmary, reviewed the growth and development of the medical school. He noted, “…
that if the standard of general culture is distinctly raised by all the advantages of uni-
versity education, … then as the numbers of those participating in this education is
increased the status of the medical profession is certain to be raised … every encour-
agement should be given to participate in all the advantages to be gained by a few
years experience of university life” (Collier 1904, pp. 223–224).
In 1905, William Osler (later Sir William; 1849–1919), a polymath clinician-
historian-scholar who had worked under Burdon-Sanderson two decades earlier,
followed as Regius Professor of Medicine. In 1913, the neurophysiologist Charles
Scott Sherrington (later Sir Charles; 1857–1952) was appointed Waynflete
Professor of Physiology; and in 1920 Archibald Edward Garrod (later Sir
Archibald; 1857–1936), a pioneer of biochemical genetics, was appointed Regius
Professor of Medicine, while Benjamin Moore (1867–1922) was appointed
Professor of Biochemistry.
A critical development in medical education in England, was the analysis and
recommendations of the “Haldane Commission” of 1909, the final report of which
was published in 1913 (Royal Commission… 1913). Chaired by Lord Richard
Burdon Sanderson Haldane (1856–1928), a barrister, liberal politician, and Lord
Chancellor (and brother of Oxford physiologist John Scott Haldane (1860–1936)),
the Commission sought to elevate medical training to a proper university education.
Influenced greatly by both the German and developing American models, Haldane’s
views were reinforced by the witness of both Sir William Osler and Abraham
Flexner (1866–1959), the latter whom recently had published his Medical Education
in the United States and Canada (Flexner 1910), as well as Medical Education in
Europe (Flexner 1912). Osler had been one of the original academicians (Chief of
Internal Medicine) at the Johns Hopkins School of Medicine in Baltimore (founded
in 1889). In an essay Osler prepared for the Quarterly Review regarding the Report
of the Haldane Commission, as well as comments regarding Flexner’s latest study,
he pointed out the major deficiency of the London Medical Schools.
3.4 The Oxford Medical School and Further Developments in Physiology 55

It is a remarkable fact … in the history of medicine in England that a complete medical

faculty of a University did not exist until well into the last century. Neither Oxford nor
Cambridge has ever had one, nor has London, for the University of the greatest city of the
world’s greatest empire is a compound educational polyzoon, the units of which, like the
polypoides, though highly organized and with admirable vegetative and reproductive
organs, are without heart or central nervous system. This higher organization the
Commission proposes to supply in the remodeled university; but, in the case of medicine,
problems of extraordinary difficulty have to be met.
(Cushing 1925, vol 2, p. 363)

After discussing the ways in which these challenges could be accomplished,

Osler concluded,
There is a new outlook in Medicine, and a new science is moulding both thought and prac-
tice. Vested interests are powerful, old associations and ways are strong, but stronger still,
we hope, will be the public and professional opinion in favour of the changes suggested by
the Commissioners. London should be the most important medical centre in the world. That
it is not this, is due to lack of organization and cohesion. To unite into a great Faculty its
scattered forces is one aim of this able and far-reaching report, which will have the active
support of all but those whom fear of change not only perplexes but appals.
(Cushing 1925, vol 2, p. 363)

Because of the turmoil of the Great War which erupted soon thereafter, however,
this goal was not initiated until much later.
In influencing the ultimate change in the philosophy of medical education and
the development of physiology in the UK, several factors proved to be important.
These included the fact that with the ever increasing pace of scientific research the
curriculum always will contain an element that is obsolete. In particular, fields such
as microbiology, pathology, and other basic sciences were rapidly advancing and
specialization in medicine was expanding with each organ system being overseen
by those who devoted their lives to understanding the pathophysiology and clinical
aspects of specific diseases (Poynter 1970).
Despite the new building for pathology and physiology at the beginning of the
century, at the end of the war, for the most part Oxford laboratory facilities for the
medical sciences were antiquated and inadequate. The new department of pharma-
cology under the direction of James Andrew Gunn (1882–1958), commenced in
1912, but was consigned to the attic of the University Museum. During this period
and continuing to 1930, the number of Oxford preclinical students rose from 25 to
about 50. Credited with providing both impetus and a blueprint for reform of the
Oxford medical curriculum were both Sir Walter Morley Fletcher (1873–1933),
secretary of the Medical Research Council, and several reports of Abraham Flexner,
at this time with the Rockefeller Foundation (Webster 1994).
In 1928, Edward Farquhar Buzzard (later Sir Farquhar; 1871–1945), a Harley
Street neurologist and physician to the King, was appointed Oxford’s Regius
Professor of Medicine. With his vision and personal alliances, Buzzard had a pro-
found influence on the development of physiology and the biomedical sciences. To
help further in establishing the Medical School, several years later the University
funded four endowed medical professorships. In 1939, the onset of the second
World War presented the unexpected opportunity for Oxford to transition to a full
56 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

and complete school of medicine, a prospect grasped by Buzzard and his confreres.
This development, which previously had engendered so much controversy, was
appreciated to be the only responsible reaction to the demands of wartime emer-
gency. Coupled with this, was the requirement for many students in the London
schools to be dispersed out of the metropolis. Ensuing developments demonstrated
the virtues of this scheme. In 1942, a governmental committee on medical educa-
tion, headed by Sir William Macnamara Goodenough (1899–1951), Chairman of
Barclay’s Bank, requested the university to outline its long-term commitment
concerning the education of medical students. In response, a committee chaired by
Buzzard, detailed the need for the Oxford clinical school to train the future leaders,
teachers, and investigators in medicine. With passage of the National Health Service
Act of 1946, the Radcliffe Infirmary, the Churchill Hospital, and several other local
hospital facilities became amalgamated under a Board of Governors into the United
Oxford Hospitals. Following planning for further extension, the John Radcliffe
Hospital at Headington was opened as a contemporary 1,000 bed teaching hospital
(Phase I, 1971; Phase II, 1979). The Phase I building included the relocated Nuffield
Institute for Medical Research (see below). As noted by one historian, “Thus …
after more than a century of vacillation, Oxford had come to terms with its role as a
complete medical school. It was at last recognized that the presence of large num-
bers of clinical students … need not subvert Oxford’s aspirations as a great centre
of medical progress” (Webster 1994, p. 343). Several writers have detailed the
development of physiology and medical education at Oxford (see Acland 1890;
Burdon-Sanderson 1892; Chaplin 1919, 1922; Collier 1904; Franklin 1936;
O’Connor 1988; Poynter 1966a, b; Rolleston 1936; Webster 1994).

3.5 The Nuffield Institute for Medical Research

In view of the seminal role Oxford’s Nuffield Institute for Medical Research (NIMR)
played in the development of fetal and neonatal physiology, and the manner in which
its program flourished, it may be of value to consider some of its background. In what
would later house the Nuffield Institute, the Radcliffe Observatory opened in 1794
following commencement of its construction in 1772 (Fig. 3.1c). Known as the
“Tower of the Winds, after the structure in Athens (~100 BCE) upon which it was
based, the structure was funded by the will of John Radcliffe (1650–1714). Known as
“the Aesculopius of his age,” Radcliffe was physician to King William III (1650–
1702; King of England 1689 to death) and Queen Mary II (1662–1694; Queen of
England, Scotland, and Ireland, 1689 to death), and then to Queen Anne (1665–
1714); Daughter of King James II (1633–1701); Queen of England, Scotland, and
Ireland (1702–1714) (see Macmichael 1827). Designed by the English architect
James Wyatt (1746–1813), the observatory was not erected until 80 years following
the donor’s death.
The stimulus for situating and building the Observatory, was the 1769 transit
of the planet Venus across the Sun, a phenomenon that occurs in pairs spaced 8
years apart every 105 or 120 years. Tracking the transit from different parts of
3.5 The Nuffield Institute for Medical Research 57

the world and employing triangulation with a combination of the parallax

method (a displacement or difference in apparent position of an object view
along two different lines of sight), and Johannes Kepler’s (1571–1630) laws of
planetary motion, provided to astronomers a more accurate knowledge than pre-
viously had been available, of the distance of the earth from the sun, e.g., the
“astronomical unit.” This then could be used to determine other distances in our
solar system, and even to distant stars. Due to a combination of inclement
weather and other complications, observations gave few details of the previous
transit in 1761. Because the second transit was predicted to be observed opti-
mally in the South Pacific, Lieutenant (later Captain) James Cook (1728–1779)
[also later early circumnavigator of the globe] was sent to Tahiti where the phe-
nomenon was observed on 3 June 1769. These measurements, combined with
those of other parts of the globe gave the distance to the sun to within 1 % of
what now is known to be correct. In Oxford, the transit was observed by the
Astronomer Royal and Savilian Professor Thomas Hornsby (1733–1810). This
experience led Hornsby to petition for Radcliffe funds to erect a proper observa-
tory. Also of note, the transit was followed the next day by a total solar eclipse
seen across Europe as well as at Oxford. Accompanying Cook on the Endeavour’s
voyage to the South Pacific, was the naturalist Joseph Banks (later Sir Joseph;
1743–1820) who, with the collaboration of Carl von Linné [Linnaeus] (1707–
1778) and his binomial classification of plants, animals, and minerals (Linné
1735), helped to enhance British imperial and commercial botanical and agri-
cultural interests. The Radcliffe Observatory was constructed in an east–west
alignment, the east wing containing the finest of John Bird’s (1709–1776) mural
quadrants, and the west wing containing teaching instruments. Finally, in 1795
the observatory tower for a large telescope was completed. In ensuing years,
with improved accuracy of the instruments, the eminence of the observatory
came from Hornsby’s meticulous observations and timing. These allowed pro-
duction of tables for nautical almanacs that through accurate determination of
longitude, facilitated navigation at sea, and thus the ascendency and near domi-
nance of Britain in world trade.
Until 1935, the Radcliffe Observatory was occupied by astronomers who made a
number of important discoveries. In 1930, with knowledge that the astronomers
would vacate the observatory in the near future, Sir William Richard Morris (later
First Viscount, Lord Nuffield) (1877–1963) (Fig. 3.1d), founder of Morris Motors
Ltd. in Oxford, purchased this and adjoining land to allow expansion of the Radcliffe
Infirmary. Several years later, in 1933, Sir Edward Farquhar Buzzard, proposed
establishment of Institute for Medical Research in the Observatory. It is said that,
Buzzard “… from the outset [had] fathered the whole scheme, and whose hope it is
that this new department may not only link the science and practice of medicine in
Oxford, but may also become a centre of national importance for the prosecution of
original research” (Franklin 1936, p. 444).
At this time, Lord Nuffield also was persuaded to endow funds for research.
Critically, Sir Hugh William Bell Cairns (1896–1952), who had come to Britain as
a Rhodes Scholar from Australia to train a neurosurgeon, and had worked with
58 3 Oxford and the Development of Physiology, with Notes on the Nuffield Institute…

Harvey Williams Cushing (1869–1939) in Boston, became a notable and charis-

matic leader, dedicating himself to creating Oxford as the “Harvard of the British
Empire.” This he planned to accomplish by establishing a postgraduate school of
clinical research, with departments lead by investigator-clinicians of outstanding
ability, who would devote themselves to teaching and research. In 1935, Cairns
prepared a memorandum on “The desirability of establishing a complete school of
clinical medicine in Oxford,” which he sent to Buzzard. The following year, in his
1936 Presidential Address “And the Future” to the Oxford meeting of the British
Medical Association, Buzzard stressed the importance of University based research
centers for the advancement of medical science, and their contributions to raising
the standard of health of the people of Britain (Buzzard 1936). Lord Nuffield was
present at the address, and with the influence of Buzzard, Cairns, and perhaps oth-
ers, was convinced to give £2 million (£120 thousand for building, with balance for
Endowment). In a munificent act, shortly thereafter Lord Nuffield pledged addi-
tional funds for the clinical school, which enabled establishment of several Nuffield
chairs in clinical subjects (Booth 1989; Minns 1994). Soon, Cairns was appointed
the first Nuffield Professor of Surgery, and Leslie John Witts (1898–1982) became
the first Nuffield Professor of Medicine. In his 1941 Harveian oration for the Royal
College of Physicians in the early years of World War II, Buzzard addressed chal-
lenges to medical practitioners, submitting in skeletal form a plan for reorganization
of medical education, with increased emphasis on environmental and preventive
medicine, social medicine, and the regional organization of medical centers
(Buzzard 1942). He emphasized the promise of the Nuffield Institute as a “research
centre” contributing to the atmosphere essential for education and progress (Booth
1989; Buzzard 1936).
In 1934, James Gunn the Professor of Pharmacology, was appointed Director of
the Nuffield Institute (although astronomers continued to occupy the building for
another year). Joining Gunn in 1936 was Alfred Ernest Barclay, a radiologist who
had moved from Cambridge following his frustration at receiving little support at
that institution (Weatherall 2000). Together with the physiologist Kenneth James
Franklin (1897–1966), these investigators focused on cine-radiography of the circu-
lation. As has been recorded elsewhere, a Remit attached to Lord Nuffield’s dona-
tion specified that cine-radiography should constitute a major focus of the Institute,
and later this was specified in the Oxford University Calendar of 1948 (Liggins
1998, p. 113). Establishment of the Nuffield Institute also contributed to develop-
ment of a postgraduate medical school at Oxford (Webster 1994).
As noted earlier, in 1944 Barclay and colleagues published the gist of their previ-
ous 7 years work on cine-radiographic and anatomical studies in The Foetal
Circulation… and the changes that they undergo at Birth (Barclay et al. 1944). In
the Preface to this volume, they credited Barcroft and Barron for stimulating their
collaborative effort, stating “The foetal studies at the Nuffield Institute were initi-
ated in 1937 when Sir Joseph Barcroft and Dr. D.H. Barron asked if we would co-
operate, with our cineradiographic techniques, in the solution of their problem,
namely, the determination of the time of functional closure of the ductus arteriosus.”
As noted earlier, the authors noted that this collaboration arose from Barron seeing,
References 59

at a March 1937 meeting of the Physiological Society in London, the “X-ray

cinematographic film of a dog’s heart” by Franklin, immediately following a film
“Experimental ‘chronic’ lesions in the central nervous system of the sheep’s foe-
tus,” that he had made with Barcroft. In this preface, Barclay and colleagues also
observed that in addition to providing “… most of our apparatus,” Lord Nuffield “…
has shown a personal interest in our results” (Barclay et al. 1944, p. v). The authors
emphasized that their chief interest in the Institute was “… to discover more about
the human subject” (Barclay et al. 1944, p. vi).
In 1943, the Nuffield Foundation was established. Gunn retired in 1946, and
Franklin became Acting Director. Soon however, Franklin left Oxford to Chair the
Department of Physiology at the University of London. In 1947, Barclay assumed
the post as director, and appointed Gordon Melville Ardran (1917–1994) as radiolo-
gist, a position he retained until 1978, when he assumed the Oxford Chair of
Radiology. Later, Ardran served as a consultant to the Atomic Energy Research
Establishment at Harwell and contributed to methods of protection from radiation
(Golding 1994). With the strength of Oxford’s other basic science departments,
establishment of the Nuffield Research Institute in proximity to the Radcliffe
Infirmary was seen as a critical factor in the establishment of clinical training at the
medical school.
In 1948, Geoffrey S. Dawes was appointed Director of the Nuffield Institute, and
over a period of several years the physiology of the developing fetus became the
focus of research. In 1970, the Institute moved from the Observatory on Woodstock
Road to Osler Road, Headington, site of Lord Nuffield’s Manor House Estate,
where it was connected with a bridge to the new John Radcliffe Hospital,
Departments of Obstetrics and Gynecology and Paediatrics. The Observatory then
became part of Green College.

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Chapter 4
Geoffrey S. Dawes: A Life in Science

4.1 Early Life and Work

Again, in view of his seminal role in the evolution of this field of study, it is perhaps
not inappropriate to consider the contributions of Geoffrey Sharman Dawes
(Fig. 4.1a). Born in Mackworth, Derbyshire, England on 21 January 1918, Dawes
was the youngest of five children. His father William Dawes (1874–1943) a graduate
of Emmanuel College, Cambridge University, was the vicar of Elvaston with
Thulston in Derbyshire. His paternal grandfather, the Reverend Josiah William
Dawes (1844–ca. 1914) a farmer and auctioneer, was also vicar of All Saints
Cathedral, Liverpool. His great grandfather was Josiah Belton Dawes (1813–1878).
Initially, Geoffrey, called “pugface” by his brothers, attended the preparatory school
Shardlow Hall, and later the Repton School, also in Derbyshire. In his final year,
Dawes was awarded the Senior House Prize for verse, a foretaste of his literary
ability and distinction. As a youth, Dawes spent considerable time fishing and
hunting in the countryside surrounding the commodious vicarage, Thurlaston
Grange, in which he was raised. With a tennis court on the premises, he became
first-rate in that sport. Although his parents planned for Geoffrey to follow the
family tradition and attend Cambridge, he was awarded a place at New College,
University of Oxford, where he gained first class honors in physiology. Following
award of a Bachelors of Science degree (1939), he qualified in medicine (1943). On
15 April 1941, Dawes married Margaret Joan Monk born in 1918 in Singapore, the
daughter of Harold Monk (1890–1930) the District Commissioner of Malaya, and
Violet Jones (1891–1990). Over the years, they had four children: Caroline Harriet
Maunsell OBE, b. 22 August 1943; Alison Jennifer Williams, b. 3 June 1945;
Nicholas William Dawes DPhil, b. 20 June 1948; and Martin Geoffrey Dawes MD,
b. 18 September 1954.
Following obtaining his medical degree, Dawes served as House Physician
working with Leslie John Witts (1898–1982), Oxford Professor of Clinical
Medicine. In the cataclysm of World War II in Great Britain every able bodied man

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 63
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_4, © American Physiological Society 2013
64 4 Geoffrey S. Dawes: A Life in Science

Fig. 4.1 (a) Geoffrey Sharman Dawes (1918–1996). (b) Otto Krayer (1899–1982). (c) Detlev
Wulf Bronk (1897–1979)

was called into military service. Because of his severe asthma with frequent attacks
of status asthmaticus, Dawes was exempt from duty. Thus, he then spent a compul-
sory year in clinical practice in St. Giles, working with Robert Emlyn Havard
(1901–1985). (Later, Geoffrey’s son Martin Geoffrey also worked with Dr. Havard’s
medical group for several years). In addition to his work as a general practitioner,
in medical science “Humphrey” Havard made several contributions to exercise
physiology. Also of note, he was the only non-literary member of the “Inklings”, a
1930s and 1940s Oxford writer’s group that included the noted authors Clive
Staples Lewis (1898–1963) and John Ronald Reuel Tolkien (1892–1973). The
“Inklings” provided mutual encouragement, critique, and editorial assistance to
one another. At their weekly Thursday evening dinner meetings, often in C.S.
Lewis’ Magdalen College rooms, the members would read works-in-progress.
Then they often would retire to the St. Giles pub “Eagle and Child” (also called the
“Bird and Baby”) for continued conversation (Carpenter 1978; Charlton 2009;
Glyer 2007). Havard has written of his relations with fellow “Inklings” and his
patient J.R.R. Tolkien (Havard 1990).
In 1944, following his posing a rather perceptive question to the Oxford pharma-
cologist Professor Joshua Harold Burn (1892–1981), Geoffrey was invited to join
the latter’s research group. Here, he worked on several pharmacologic compounds
(atropine and its substitutes, benzamidines, and quinidine, the veratrum alkaloids,
and quanidines) as they related to the military and the war (Dawes 1945, 1946a, b, c).
Following the war (1945), Dawes was elected a Tutorial Fellow in Physiology, the
first such scientific Tutor, at Worcester College (1946–1948). Although officially
founded in 1714, Worcester College dates from the late-thirteenth century when Sir
John Giffard (1232–1299) purchased Gloucester Hall, and presented it to the
Benedictine order as a “nursery and mansion place” for their novices. Following
the Act of Supremacy (1534) with Dissolution of the Monasteries (1537–1540) by
Henry VIII (1491–1547; King of England 1509–1547), the monastic buildings were
given by the King to the new Anglican See [Latin sedes, seat] of the Bishop of
4.1 Early Life and Work 65

Oxford. In the early-eighteenth century, the Worcestershire baronet, Sir Thomas

Cookes (1648–1701) left a benefaction for the foundation of a new College. Several
notable eighteenth century architects including Sir George Clarke (ca. 1661–1736)
and Nicholas Hawksmoor (ca. 1661–1736) designed the college central buildings,
including the chapel and library.
In what was to prove a life-changing experience, Dawes then obtained a
Rockefeller Foundation Traveling Fellowship, and during the academic year 1946–
1947 worked with two authorities in regulation of the cardiovascular system. The
first was Otto Krayer (1899–1982) (Fig. 4.1b), chairman of the Department of
Pharmacology at Harvard Medical School, and a pioneer in studies of the pharma-
cology and autonomic regulation of cardiac function. A master mentor, Krayer
inspired investigators in his department to explore important pharmacologic ques-
tions and develop new research methodologies (Reiter and Trendelenburg 1982).
Dawes was to benefit greatly from this philosophy during his years leading the
Nuffield Institute. In Krayer’s laboratory, Dawes determined the sites of action of
veratrum alkaloids in the lungs and coronary arteries (Dawes 1947, 1951).
For the second half of his Fellowship, Dawes moved to the University of
Pennsylvania in Philadelphia, where he worked with Detlev Wulf Bronk (1897–
1975) (Fig. 4.1c) in the Johnson Foundation for Medical Physics (named for
Eldridge Reeves Johnson (1867–1945) and established in 1929). “Det” Bronk, a
world leader in establishing the field of biophysics, explored several aspects of
neurophysiology. With Dawes’ background in pharmacology, it appears obvious
why he would choose to work with Krayer. It was Bronk’s innovative studies on
neural regulation of cardiovascular function and blood pressure that probably led
Dawes to choose to work in his laboratory. Another factor may have been a seminal
1944 paper Bronk wrote on “The Discovery and Interpretation of Biological
Phenomena”. In referring to the English philosopher and essayist Francis Bacon,
Bronk stressed the importance of the scientist’s requirement for freedom of
inquiry, the merits of groups of investigators collaborating in fields of inquiry,
pursuing clarified directions of research, and the need for cooperation and mutual
encouragement in a multidisciplinary program under control of the scholars
alone (Bronk 1944). With such freedom and support, Bronk maintained that, “…
the ablest minds in the country will … be recruited for the discovery of natural
knowledge” (Bronk 1944, p. 312). As Director of the Nuffield Institute for almost
four decades, it was to these concepts and principles that Dawes adhered. While
at the Johnson Foundation, Dawes learned techniques of electrophysiology with
the idea of using these to study the mechanism of action of veratrum compounds,
and their responses and effects on the circulatory and respiratory systems (Dawes
1947; Dawes and Comroe 1954; Dawes and Fastier 1950; Dawes and Feldberg
1949; Dawes and Mott 1950; Dawes et al. 1951a, b). A gifted administrator as
well as scientist, during World War II Bronk had served as a special consultant to
the Secretary of War, and was Chief of the Division of Aviation Medicine,
Committee on Medical Research of the U.S. Office of Scientific Research and
Development (OSRD). These experiences and associations led to his appoint-
ment in 1945 as Foreign Secretary of the National Academy of Sciences (NAS),
66 4 Geoffrey S. Dawes: A Life in Science

and in 1946 as Chair of the National Research Council (NRC). Following Dawes’
sabbatical, Bronk assumed the Presidency of the Johns Hopkins University
(1949) and the National Academy of Sciences (1950), and received many other
honors (Brink 1979). In retrospect, it is tempting to speculate on Bronk’s influ-
ence on Dawes’ thinking in terms of experimental investigation and the nature of
the scientific enterprise. Although they published no papers together, and in
Dawes’ writing I can find no definitive evidence, it appears clear that Bronk
played more than a minor role in the development of his philosophy of life and
career. For instance, Bronk had a great interest in the regulation of the cardiovas-
cular and pulmonary systems, and cerebral oxygenation. Regarding the satisfac-
tion of a life as an investigator, he observed “… for we have a rare opportunity to
glimpse the essential unity of science. To comprehend this is the final objective
of every natural philosopher” (Bronk 1938, pp. 139–142). In his 1953 Presidential
Address of the American Association for the Advancement of Science, Bronk
stressed the intellectual adventure that constitutes scientific research and inquiry,
and also the responsibility of scientists to serve in the public arena. He closed
with the words from Arthur Dehon Little (1863–1935),
Ours is the duty and privilege of bringing home to every man the wonders, the significance,
and the underlying harmony of the world in which we live to the end that all undertakings
may be better ordered, all lives enriched, all spirits fortified.
(Bronk 1954, p. 227)

Upon his return to Oxford in 1947, the Royal Society awarded Dawes a Foulerton
Research Fellowship. Throughout his career, Dawes continued to employ electronic
technology in his research studies, yet would remain a classical organ/systems
physiologist-pharmacologist.
The following year, February 1948, the youthful Dawes was invited to become
Director of the Nuffield Institute for Medical Research. At this time he was 30
years of age, with eight publications to his credit. Quickly, he dedicated himself
to building the Institute. A complicating problem was that Dawes possessed
strong reservations about the value of radiology and/or cine-radiography as a tool
to study physiologic mechanisms, and resented the stipulation in the Institute’s
statutes specifying the importance of radiography to the research program. He is
said to have clashed frequently with Ardran over this issue (Liggins 1998, p. 114).
A year following his appointment as director, Dawes was joined by a physicist-
electronic engineer Derek G. Wyatt and the zoologist Joan Culver Mott (1921–
1994) (Fig. 4.2b), to collaborate on studies of cardiovascular and respiratory
reflexes (Dawes and Mott 1950, 1959; Dawes et al. 1951a, b, and others; Wyatt
1957, 1961); Dawes and Mott 1959). With David Whitteridge (1912–1994), who
left soon thereafter to assume the Chair of Physiology at the University of
Edinburgh, he collaborated on single-fiber recording of nerve impulses. Together,
with pieces of equipment purchased at war surplus sales, they constructed an
oscilloscope, nerve stimulators, and time-basis amplifiers. With Marjorie
Prichard, Dawes commenced his studies on the pulmonary circulation (Ardran
et al. 1952). Regarding Dawes’ appointment, John Guy Widdicombe (1925–2011)
(Fig. 4.2c) of University of London, and who worked with Dawes in the early
4.1 Early Life and Work 67

Fig. 4.2 (a) Nicholson J. Eastman (1895–1973). (b) Joan C. Mott (1921–1994). (c) John G.
Widdicombe (1925–2011). (d) Dawes Fishing (ca. 1970)

1950s, recalled, “His appointment had been a leap of faith on the part of the
Oxford University authorities, fully justified as the years passed. Geoffrey …
[stated] that he had confided to David Whitteridge … that he had no idea how he
would sustain a research programme. Whitteridge had assured him that ‘one thing
will lead to another’ and that is how it worked out” (Letter from JW to LDL, 27
March 2009).
In reflecting upon his contributions to fetal and neonatal physiology, one may
consider Dawes’ career in four distinct periods: cardiovascular studies of the 1950s
through the 1970s, studies on the fetal and newborn asphyxia and the pulmonary
vasculature during the 1960s, the exploration of fetal breathing activity beginning in
the 1970s, and from the early 1980s until the end of his career investigation of fetal
heart rate and its variability.
68 4 Geoffrey S. Dawes: A Life in Science

4.2 Dawes and the Fetal Cardiovascular System:

The 1950s and 1960s

Following the trauma of World War II, the internal enemy of disease replaced the
external axis powers as the greatest threat to the world. As a consequence, com-
mencing with only modest funding the “golden age” of research in medicine arose
phoenix-like from the ashes. Although the war was enormously disruptive to civili-
zation and to life, one side effect of benefit was the advance in instrumentation and
technology, which investigators could apply to the furtherance of science. Dawes
was one who took great advantage of these developments. It was in 1950, that
Samuel Reynolds (Fig. 4.3a, b) commenced a year sabbatical at the Nuffield
Institute (Reynolds 1978). On the basis of some of his studies at the Carnegie
Institution, Reynolds had postulated that umbilical venous return from placenta to
fetus was driven by the pulsations of the umbilical arteries within the umbilical
cord, rather than by the vis a tergo [driving force]. With use of the angiographic
cine-radiographic expertise of Ardran and the Nuffield group, he hoped to resolve
this question. Of vital importance to his career, Dawes has recorded that stimulated
by Reynolds’ impending visit, he read both the work by Barclay and colleagues The
Foetal Circulation… (1944), and Barcroft’s monograph, Researches on Pre-natal

Fig. 4.3 (a) Samuel R. M. Reynolds (1903–1982). (b) Title page (1954)
4.2 Dawes and the Fetal Cardiovascular System: The 1950s and 1960s 69

Life… (1946). This experience was an epiphany of sorts, changing his life course.
In these two volumes, both Barclay and coworkers and Barcroft outlined a number
of functional aspects of the fetal cardiovascular system and its regulation, including
that of cardiac output, the pulmonary circulation, the ductus arteriosus, the changes
at birth, and so forth, that were poorly understood or not understood at all. These
volumes outlined Dawes’ experimental studies for the next two decades. He grasped
quickly the “… obvious that there were major gaps in knowledge and the field had
a good prospect for development.” Of importance, he appreciated,
… the possibility that by examining the mammalian organism in the course of development we
might be able to identify a period of life at which the organization of the control systems which
determine homeostasis is simpler than in the adult, and that we could begin to understand how
these mechanisms are assembled to form a coherent whole. It could be that in the fetus one
would deal with systems which are free of many of the complexities of independent adult life.
(Dawes 1981, p. 1)

The circulatory system of the fetus is unique in having four major shunts, e.g.,
the ductus arteriosus between the left pulmonary artery and aorta, the foramen
ovale between the two atria, the ductus venosus a channel joining the abdominal
portion of the umbilical vein and inferior vena cava, and the placental circulation.
During the following years Dawes and the Oxford group devoted considerable
effort to elucidate the roles and dynamics of these (Born et al. 1954, 1956b; Dawes
1961, 1963, 1965a; Dawes et al. 1954, 1955b, c, 1956). While the circulation of the
fetus had been described in terms of anatomical-systems, Dawes saw that little to
nothing was known of either the quantitative aspects or the physiologic regulation
of cardiovascular flows or pressures. In addition, he realized the vast ignorance that
existed in regard to the pulmonary circulation, and the profound changes these sys-
tems undergo at birth (Dawes 1981). In particular, he appreciated that there was no
rational basis “… of how ventilation in the lungs at birth, caused a redirection of the
fetal circulation … It became evident that this was a more complicated system than
it had first appeared …” (Dawes 1994, p. 2). Several decades later, Dawes would
recall, “… the mechanisms that controlled this [the changes in the fetal circulation
at the time of birth] continued to provide food for thought and experimentation for
years” (Dawes 1994, p. 2). In addition, he understood the importance of the prob-
lems of growth and development, the fetal lamb increasing in weight nearly 5,000-
fold between 40 dpc and term, ~140 dpc (Dawes 1981). In later essays, he stated
that in reading Barcroft, he realized that this synopsis “… raised more questions
than answers” (Dawes 1984, p. 259), and he reviewed other aspects of the develop-
ment of his thinking along this line (Dawes 1985).
In a series of studies over the next decade and a half, Dawes demonstrated the
manner in which the various elements of the fetal cardiovascular system respond
readily to stimuli (reviewed in Dawes 1966). Although the experiments proposed
by Reynolds did not support his hypothesis on the role of arterial pulses driving
umbilical venous blood flow, the group published their first report on the role of
the autonomic nervous system in cardiac reactivity. Sympathetic stimulation or
atropine administration increased heart rate, while vagal stimulation, thoracic
70 4 Geoffrey S. Dawes: A Life in Science

sympathectomy, or propranolol (alpha adrenergic receptor blocker) resulted in

bradycardia (Dawes et al. 1956). In addition, these workers demonstrated conclu-
sively the remarkable lability of the pulmonary vascular bed, and the effect of
ventilation of the fetal lung in lowering pulmonary vascular resistance with an
abrupt increase in blood flow (Ardran et al. 1952). They also demonstrated that the
lowered resistance of the pulmonary vasculature was mediated not only by oxy-
gen, as it also occurred with ventilation with nitrogen (but not saline) (Ardran
et al. 1952; Cassin et al. 1964a, b; Dawes and Mott 1962). In light of these studies,
Dawes rejected his original hypothesis that the relatively high pulmonary vascular
resistance was a consequence of the “kinking” of small resistance vessels (Dawes
and Mott 1962). Although he demonstrated that acetylcholine infusion dilated the
pulmonary vascular bed, increasing flow (Dawes and Mott 1962), a more exact
mechanistic explanation for these changes had to await the discovery of the vaso-
dilators prostaglandin and nitric oxide. In a later survey of his experiments during
this period, Dawes recalled that his studies rarely were carried out in a warm saline
bath, as those of Huggett, Barcroft, and coworkers. Rather the anesthetized ewe
was placed on her side on an operating table, and the fetus placed on a “smaller
adjustable warmed table elevated a few inches and pressed against the maternal
abdomen… without tension on the umbilical cord” (Dawes 1994, p. 2). The fact
that these studies were conducted under anesthesia, rather than in a chronically
catheterized unanesthetized preparation (which was not described until a decade
later), would prove a major limitation to their interpretation.
Several questions were germane at this time. Although the Nuffield group had
demonstrated the remarkable sensitivity of the fetal pulmonary vascular bed to cat-
echolamines and acetylcholine, the extent to which the variation in pulmonary vas-
cular resistance was related to ventilation per se, as opposed to the role of the
autonomic nervous system, remained unclear. In preparations with bilateral thoracic
sympathectomy and vagotomy, they demonstrated the lack of importance of the
latter nerve (Colebatch et al. 1965). Dawes and collaborators also explored the
question whether fetal pulmonary vasodilatation associated with ventilation with
the several gas mixtures might arise from pulmonary vascular receptors. They dem-
onstrated this not to be the case, as a single inflation with a low oxygen mixture
(3 % O2, 7 % CO2, with no significant change in arterial blood gases) resulted in
prolonged vasodilatation, both without and following bilateral thoracic sympathec-
tomy and vagotomy (Colebatch et al. 1965). A further question of relevance was the
extent to which increases in arterial Po2 and/or decrease in Pco2, as opposed to the
liberation of local blood-borne vasodilators, play the dominant role in lowering pul-
monary vascular resistance at birth. In a series of studies in premature lambs com-
bining fetal asphyxia, infusion of oxygenated blood into the pulmonary artery, and
in some cases bilateral vagotomy and infusion of hexamethonium (to block sympa-
thetic nerves), the group demonstrated that, indeed, factors in addition to the blood
gases played a critical role in this regard (Cassin et al. 1964b). These studies dem-
onstrated conclusively that the basic mechanisms regulating the pulmonary vascular
bed had developed long before the time of birth or fetal viability. In addition, these
and related studies (Cassin et al. 1964a; Colebatch et al. 1965) contributed to the
4.2 Dawes and the Fetal Cardiovascular System: The 1950s and 1960s 71

concept that humoral or other yet to be discovered factors (NO and prostaglandins)
play critical roles in this regard.
During the remainder of the 1950s and into the early 1960s, Dawes and his col-
leagues focused their attention of various aspects of the changes in the circulation at
the time of birth with closure of the ductus arteriosus and the foramen ovale (see
Dawes bibliography, Chap. 23). In the normal newborn infant, the ductus closes
5–30 min following birth, followed by its gradual obliteration. Immediately follow-
ing the onset of breathing, the high velocity reversed flow from aorta to pulmonary
artery through the partially constricted ductus arteriosus creates a vibratory thrill. In
these studies on closure of the ductus with pulmonary ventilation, these workers
demonstrated abrupt constriction with increased oxyhemoglobin saturation, as well
as in response to asphyxia with increased Pco2 (Born et al. 1956b). Pulmonary infla-
tion with nitrogen did not constrict the ductus. The group also showed that raising
fetal [HbO2] by having the mother breathe 100 % O2, also was followed by ductus
constriction (Born et al. 1956b). These straightforward, well designed studies dem-
onstrated unequivocally that increased oxygen levels mediated constriction; how-
ever, they did not establish the factors causing constriction in the presence of much
lower oxygen levels. Dawes proposed that the asphyxial response was mediated by
the release of catecholamines, a fact demonstrated by infusion of either epinephrine
or norepinephrine (Born et al. 1956a). The Nuffield group performed a number of
other studies on various aspects of closure of the ductus arteriosus (Amoroso et al.
1958; Born et al. 1955; Dawes et al. 1954, 1955a, b). Because the ductus venosus
constitutes a potential porto-caval shunt that bypasses the liver, its closure at the time
of birth also is important to newborn’s well-being. Dawes and colleagues explored
some aspects of the role of this fetal vascular channel, but abandoned these studies
because of the difficulties associated with its investigation, and after demonstrating
that its closure for up to 5 min had no significant effect on carotid arterial [HbO2] or
arterial blood pressure (Dawes 1968). Other studies concerned regulation of closure
of the foramen ovale (Dawes et al. 1955c). With his background in pharmacology
and cardiovascular reflexes, to a limited extent he continued to pursue questions
related to these (Born et al. 1956a; Dawes and Comroe 1954; Dawes and Widdicombe
1953), emphasizing that the fetal heart and blood vessels (other than those of the
placenta), are under autonomic control (Dawes 1966).
With his strong interest in, and commitment to, problems of clinical relevance,
commencing in 1957, Dawes turned his attention to the oxygenation of fetal tissues,
the rates of oxygen consumption and some aspects of asphyxia on cardiovascular
functions (Acheson et al. 1957; Born et al. 1956a; Dawes and Mott 1959). By deter-
mination of oxyhemoglobin saturations in the several vessels, Dawes and colleagues
confirmed the early work of Huggett, and Barcroft with Barclay and colleagues, that
descending aortic blood was derived chiefly from the right ventricle and pulmonary
trunk via the ductus arteriosus (Dawes 1961; Dawes et al. 1954). Within minutes of
the onset of ventilation, the direction of flow through the ductus reversed, so that the
majority of descending aortic flow was from the left ventricle (Dawes 1961; Dawes
et al. 1955c). During these years Dawes also collaborated with Kenneth William
Cross (1916–1990) of St. Mary’s Hospital Medical School, London, on the
72 4 Geoffrey S. Dawes: A Life in Science

resuscitation of the newborn infant. Having worked with Huggett, Cross had great
interest in anoxia of the newborn (Cross et al. 1953, 1954). In this regard, their stud-
ies established that positive pressure ventilation was more satisfactory than the use
of either pharmacologic agents or hyperbaric oxygenation (Cross et al. 1959). A
distinguished physiologist and student of the newborn, in 1979 Cross was awarded
the James Spence Medal of the British Paediatric Association (Wolff 1979).
In the late 1950s Dawes also became interested in the phenomenon in altricial
species (i.e., those helpless at birth requiring food and care for a given period, such
as cats, dogs, rats, and humans) of increasing metabolic rate and O2 consumption in
response to exposure to cold. By administrating a curarizating agent, the possibility
of shivering was eliminated (Dawes and Mestyan 1963). In their calculation, extra
heat production from the liver was eliminated by local measurements with thermo-
couples (Dawes 1985). On sabbatical at the Nuffield Institute, the Oxford pediatri-
cian Peter Tizard (later Sir Peter; 1916–1993) with Jon Wilfred Scopes (1930–1999)
of Queen Elizabeth Hospital, London, showed in rabbits that the epinephrine-
mediated increase in O2 uptake became greatly attenuated within 3 weeks of birth
(Scopes and Tizard 1963). Also about this time at the Institute, the pediatric pathol-
ogist Michael Dawkins (1931–1965) with David Hull (later Sir David), observed
attenuation of adipose tissue deposits around the young rabbit neck and interscapu-
lar region over this same newborn period. Upon exposure to cold, this brown adi-
pose tissue (as it was known later) became much warmer than the rest of the body
(Dawkins and Hull 1964; see below). This helped to provide a satisfactory explana-
tion of the response to cold in the human infant (Dawes 1985).
A related key issue at this time was the lack of knowledge of the quantitative
values of blood flow through the foramen ovale or the ductus arteriosus, and the
extent to which output of the right and left ventricles were similar or differed. Dawes
came to appreciate that measurements of O2 content and oxyhemoglobin saturation
could be used to quantify the relative amounts of blood flow through the major ves-
sels, and the individual ventricular outputs. By measuring simultaneously the O2
content at eight separate sites, he calculated the combined right and left ventricular
output flow to the lungs (~10 %), to the placenta (57 %), with the balance to the
remainder of the fetal organs. He also calculated that a considerable volume of car-
diac output transits the foramen ovale (40 %), ductus arteriosus (35 %), and aortic
isthmus (38 %). Although he argued incorrectly that output of the left ventricular
greatly exceeded that of the right, he estimated that blood admixture within the heart
was of little consequence, because of the large flow returning from the placenta
(Dawes 1961, 1965b). In a highly cited review, Dawes summarized his and others
work on the fetal circulation and the changes at birth (Dawes 1961). He later
reflected on this series of contributions, “There is a wide variety of distinct physio-
logic mechanisms, each separate and yet independent, subtle, elusive, and beautiful,
which together comprise the circulatory system. … If there is one single lesson that
has been learned from the last 10 years, it is that the circulation in the fetus and
newborn is not a simple, less sophisticated, passive, smaller replica of the adult, but
a complex, adaptive mechanism which continues to offer a worthy challenge to the
investigator” (Dawes 1966, p. 78).
4.2 Dawes and the Fetal Cardiovascular System: The 1950s and 1960s 73

In recalling the early years at the Nuffield Institute and his involvement in these
studies, John G. Widdicombe has written,
The arrangement of the building at the time was as follows. One passed through the imposing
portico to the large entrance hall with its beautiful circular oak table. Here everyone, research
workers, technicians, secretaries and visitors came for coffee each morning and tea each after-
noon. Democracy was complete. Technicians were valued and made important contributions.
In the right wing was first, Geoffrey’s room, then Derek Wyatt’s (a physicist), then a small
room (first occupied by Gwen [Barer] and later by Janet Vaughan, Principal of Somerville
College), and then the workshop occupied by Bill Dodson, Arthur Broadway, and an electron-
ics technician. Geoffrey always encouraged his assistants to make their own apparatus, and
often there was no choice. In [my] D. Phil. viva Whitteridge, one of the two examiners, asked
… ‘Did you build your own amplifiers?’ Thanks to Geoffrey [I] was proud to reply ‘Yes’. On
the left hand wing was Ardran and the radiology laboratory run by the radiographer Maurice
Tuckey. A small room at the back of the hall housed the secretaries. Upstairs on the first floor
was the central large laboratory with five [to] six research stations housing, at various times,
individuals or pairs: Jesse Thompson (US), John Vane … Julius Mestyan (Hungary), Vladimir
Kovacik (Slovakia), Kottegoda (Sri Lanka), Egbert Nusser (West Germany) and Karliss [sic]
Adamsons. To the right over Geoffrey’s room was the sheep room, also used by … [me] for
respiratory research when outside the lambing season. Smaller rooms to the left housed
Prichard and the photographer Eve Sporle. On the third floor was a magnificently furnished
but freezing library, from which the telescopes had originally been pushed out to the open
balconies on adjoining roofs. Above on the highest roof was a weather station. Outside beyond
the Institute was the animal house which contained other small rooms for research staff.
All floors of the Institute (except the entrance hall) had magnificent oak plank flooring.
The trouble was that it bounced and was unsuitable of apparatus that had to be vibration free.
A solution was found when part of the ground-flooring was lifted; underneath there emerged
enormous concrete blocks that Wyatt had installed for the mounting of astronomical equip-
ment, and which provided wonderful stability.
In 1950, during a visit by Sam Reynolds … Geoffrey studied the changes in the foetal
circulation at birth by cineradiography with a contrast medium, thorotrast. In this and sub-
sequent studies the foetus was delivered and lay beside the ewe, still attached by the umbili-
cal cord to the placenta. They observed the passage of blood through the ductus venosus,
the foramen ovale and the ductus arteriosus, channels open in the foetus and newborn but
which close soon after birth. This was a defining moment for Geoffrey. He realized that
accurate measurements of pressure and flow were not possible with this technique. He
largely abandoned radiology for more precise and quantitative techniques. He moved his
research from the radiological laboratory to an upstairs room, the “sheep room”. The NIMR
ceilings were very high, so he had a mezzanine platform built on which was placed Van
Slyke gas analysis and other equipment, approached by a ladder. Henceforward there was a
yearly programme of research. A farmer/research veterinarian arranged for regular tupping
(copulation) of the sheep so that the ewes could be brought in to the laboratory at known
stages of pregnancy. Geoffrey supervised the tupping himself and junior members of his
team were not allowed to attend the indelicate procedure.
An hilarious daily event was getting the heavily pregnant and reluctant sheep upstairs to
the sheep room. There was a beautiful Regency curved staircase but no lift. We learnt that
if the pregnant ewe was pressed to the wall of the stair and surrounded by 4–5 humans she
thought she was in a flock and readily followed the animal stream. The ewe was anesthe-
tized and placed on an operating table with a smaller table alongside, on which the lamb
was delivered by Caesarian section and kept warm and moist alongside the ewe and attached
to the placenta. This was in the days of post-war deprivation and food rationing; the mater-
nal carcass provided many a Sunday roast joint, its hide a thick floor rug, and the foetus
valuable Persian lamb fur for ornament. On one occasion [I] was walking home in the
middle of the night after a long experiment, with the spoils on [my] back in a large sack.
74 4 Geoffrey S. Dawes: A Life in Science

The police stopped [me]. ‘What have you there?’ [I] replied honestly but provokingly ‘a
body!’ They laughed and allowed [me] to proceed.
An early important study measured the oxygen content of blood in different parts of the
foetal circulation; from these values the flow to different regions could be roughly calcu-
lated. However there was a great need for a reliable flow measuring device. John Vane, who
arrived in the laboratory to do a D. Phil, and was later awarded a Nobel Prize for his work
on prostaglandins, designed a density flowmeter which was an advance on the ‘Volkmann-
Ludwig type’ flowmeter. This was accurate and facilitated much good work. With it the
great increase in blood flow and decrease in pulmonary vascular resistance which took
place when the newborn lamb was ventilated was now directly measured. An important
study in 1954 established the relative blood flow through different parts of the foetal circu-
lation from measurement of oxygen content in the blood at eight different sites; 57 % was
through the placenta, but only 10 % through the lungs. The high placental blood flow meant
that the mixing of blood in the right heart was not very important. In 1955 cinematography
showed that a cardiac murmur that had been detected in the newborn lamb was associated
with reversal of blood flow through the ductus arteriosus. Surgical closure of the ductus
caused a fall in arterial O2 saturation. In the late 1950s two biochemists, Heather Shelley
and Michael Dawkins were appointed. With Dr. Shelley it was shown in 1959 that the sur-
vival time of the newborn animal (work was now being done on lambs, rats, rabbits and
guinea pigs) in hypoxia was dependent on the reserves of carbohydrate in the heart. This
was an early finding that was to have important clinical implications.
The Vane flowmeter was clumsy to insert into blood vessels and required a large volume
of blood to fill it. Geoffrey had appointed a young physicist (Derek Wyatt) who set about
developing a cannulating electromagnetic flowmeter. The technical difficulties involved
were great, the chief one being to eliminate all currents except that due to passage of a
conducting fluid (blood) at right angles to the imposed magnetic current. The final instrument,
many components of which had to be made by hand, was superb and surpassed for very
many years any commercially-produced instrument. With this tool, Geoffrey went on to
determine the control mechanisms of the foetal pulmonary circulation. Geoffrey and his
team demonstrated the factors which controlled blood flow through the foetal and neonatal
lungs of the lamb. In 1960 Dawes and Mott showed that the foetal circulation was in a high
state of tone; the lung vascular resistance was due to smooth muscle activity and not simply
mechanical in origin; it was greatly reduced by the dilator activity of acetylcholine or his-
tamine while, after occlusion, there was reactive hyperaemia. Ventilation of the ewe with
100 % O2 caused vasodilatation, while maternal hypoxia, induced by ventilation with 10 %
O2 caused foetal pulmonary vasoconstriction. The demonstration of hypoxic pulmonary
vasoconstriction, the reverse of the systemic response to hypoxia which is vasodilatation,
was important; this phenomenon is retained in adult life where most think it assists adjust-
ment of local blood flow to local ventilation, although some suppose that it is a vestigial
mechanism, useful only in foetal life to reduce flow through the non-functioning lung.
Geoffrey had a great capacity to master new technology. In the early 1950s he taught
himself the use of cathode ray tubes while others were still using smoked drums. Later in
life he similarly mastered computers and with them was to do important work on foetal
heart sounds which had important consequences for the management of pregnancy.
However Geoffrey retained his interest in radiology. He decided to study blood flow
through the three-chambered heart of a reptile. At considerable trouble and cost three croc-
odiles were shipped over from the Nile. Thankfully they were small, about 30–40 cm long,
but their teeth looked sharp so plaster tape was put round their snouts. They were kept in a
bath tub. On the day of the first, and last, experiment they were anaesthetized, a venous line
was inserted, and they were placed on the x-ray machine. Thorotrast was injected and pic-
tures of the heart were taken. However we had not anticipated that all the reptilian scales
would be calcified, so that the pictures looked like a heavy snow-storm; it was the end of the
research project, and of Geoffrey’s interest in radiology.
(Letter from JGW to LDL, 27 March 2009)
References 75

Dawes’ son, Nicholas William recalled playing at the “Tower of Winds”,

When Pa was Director of Medical Research at the Nuffield Institute, a lot of the experi-
mental work was done using sheep. This early work was done in the Observatory (the
“Tower of the Winds”). This building has a gorgeous circular staircase, and the operational
work was done in rooms at the top of these stairs. Accordingly, the pregnant sheep had to
be ‘encouraged’ to walk up these stairs, which was a very memorable and extraordinary
event for us to watch, from a certain distance of course…. When we were young, some-
times one or two of us would go to the lab on weekends with Pa and stay there for a
time while he did some work. Pa was very good at blowing glass, and he would make
strange objects out it for us to play with. Also, we liked to play with the liquid mercury,
which ran about and formed and split into interesting blobs. Quite often some would get
away and be lost in the cracks in the floor. When there were sheep there, we would look at
them in their pens as well. Sometimes tiny lambs would be brought home to be kept warm
by the stove in our kitchen at home overnight. Occasionally we would be allowed to feed
them from bottles.
(Letter from NWD to LDL, 18 January 2009)

Nicholas also recollected fond memories of shooting and fishing with his
father (Fig. 4.2d),
Pa was an excellent shot with the classic English 12 gauge side by side shotgun. He and a
group of friends used to go shooting for partridge, hare and pheasant in the winter months
at a farm near Oxford where they leased the shooting rights year by year from the farmer.
We children were coopted to help as “beaters” in the line walking across the fields, then
after a while we would also help carry the game. These shoots occurred most Saturdays, and
we would either take a sandwich lunch or, later, meet at a pub before heading off.
At the end of the shoot the game would be divided out. We would normally bring some
birds home and often a hare, which usually weighed several pounds. This represented a
good deal of extra meat for us to have during the week, especially during the 1950s. He
would clean the game and taught us how to do so as well.
Pa also fished a great deal. He really enjoyed catching fish for food, considering catch-
ing fish one could not eat as being significantly less fun. He taught us all to clean fish, and
was very rapid and effective at it, as one would expect from his surgical skills. His carving
of beef and other roasts was similarly skillful.
(Letter from NWD to LDL, 18 January 2009)

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in foetal and new-born lambs. J Physiol (Lond) 135:623–643
Amoroso EC, Dawes GS, Mott JC (1958) Patency of the ductus arteriosus in the newborn calf and
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Ardran GM, Dawes GS, Prichard MML, Reynolds SRM, Wyatt DG (1952) The effect of ventila-
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Barclay AE, Franklin KJ, Prichard MML (1944) The foetal circulation and cardiovascular system,
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compounds. Acta Physiol Scand 22:73–76
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in the newborn and infant. Grune & Stratton, New York, pp 74–79
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line on the foetal circulation in the lamb. J Physiol (Lond) 134:139–148
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Chapter 5
Fetal Asphyxia and the Primate Colony
in Puerto Rico

5.1  Historical Perspective

From an historical perspective, asphyxia in the newborn infant presents a number

of issues. Although defined as “pathological changes caused by lack of oxygen in
respired air, resulting in hypoxia and hypercapnia” (Dorland 2007, p. 167), the
term is used differently by physiologists, clinicians, and pathologists. In Greek the
term means “a stopping of the pulse,” thus strictly speaking, the word asphyxia is
an “infelicity of etymology” (Eastman 1936b, p. 274). As with many definitions,
however, once it has been accepted, it may be altered to fit the circumstances. For
instance, obstetrical asphyxia is “an imprecise term… frequently based on low
Apgar scores alone…” (Cunningham et al. 1989, p. 597). Some prefer the term
“neonatal or perinatal depression” (Reece and Hobbins 2007, p. 1234). According
to a task force of the World Federation of Neurology Group, it is a “… condition
of impaired blood gas exchange leading, if it persists, to progressive hypoxemia
and hypercapnia” (Bax and Nelson 1993, p. 1022). For the neonatologist, asphyxia
is applied to “infants who require more than one minute of positive pressure ventila-
tion before the occurrence of sustained respiration.” No reference is made to blood gas
values. In contrast, hypoxia is the case in which despite adequate perfusion deficient
oxygen in the blood (hypoxemia) is associated with the O2 supply to tissues being
reduced below physiologic levels. Commonly associated with conditions of impaired
placental exchange of O2, asphyxia may result from abruptio placentae [premature
separation of the placenta from the uterine wall], prolapse of the umbilical cord,
maternal shock with hypotension, carbon monoxide intoxication, and other condi-
tions. As noted below, a link between reduced fetal oxygenation and the development
of perinatal complications such as intrauterine growth restriction and subsequent
neurodevelopmental handicaps has long been established.
It was William John Little (1810–1894) (Fig. 5.1a), a London orthopedic surgeon,
who in 1861 in a presentation to the Obstetrical Society of London, first proposed the
novel thesis in which he defined a causal relationship between abnormal parturition
with asphyxia of the newborn to subsequent neurologic damage (Little 1861/1862),

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 79
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_5, © American Physiological Society 2013
80 5  Fetal Asphyxia and the Primate Colony in Puerto Rico

Fig. 5.1 (a) William John Little (1810–1894). (b) Kenneth W. Cross (1916–1990). (c) Cayo
Santiago with Rhesus Monkey

and the syndrome that became known as cerebral palsy (Osler 1889). In this “learned
bombshell” (Neale 1958, p. 23), Little argued that besides ending in death or recov-
ery, previous medical authors “seem quite unaware asphyxia at birth and abnormal
parturition, not unfrequently has… a third termination in other diseases.” Little’s
“third termination” included a spectrum of long-term deformities and disabilities. He
postulated these were secondary to “… interruption of proper placental relation of
the foetus to the mother, and non-substitution of pulmonary respiration, ‘rather’ than
from direct mechanical injury” (Little 1861/1862, p. 298), acting on the brains of
“too early and unripe-born foetuses” (p. 314). In an appendix, Little tabulated 47
cases of spastic rigidity of the newborn and 11 related cases (p. 318ff). He noted the
varying susceptibility of the developing nervous system to damage at differing ages
of gestation. He noted further that many patients exhibited a delay in the appearance
5.1 Historical Perspective 81

of the classical signs, what now would be interpreted as a transitional hypotonic

phase. Little, with William Richard Gowers (1845–1915) after him, observed that
more extensive motor involvement was correlated with greater intellectual deficiency
(Gowers 1888). In association with this syndrome, Little also described erratic
learning, short attention span, irritability, destructiveness, aggression, ­cunning, heb-
etude and weakness of every intellectual facility, even complete idiocy.
In the discussion following Little’s presentation, one listener recounted a case of
a child born with spastic hemiplegia who was shown to have intracerebral bleeding
following a “lingering labor” (p. 343). In contrast, many of the audience probably
agreed with a discussant who stated “the difficulty … in discussing this excellent
paper, arose, no doubt, from the entire novelty and originality of the subject”
(p. 342). Later Charles West (1816–1898), a founder of the Obstetrical Society of
London, observed that he could neither confirm nor deny Little’s thesis because, “…
instances of such termination of abnormal labour had not fallen under his notice”
(West, quoted by Neale 1958, p. 24). In closing his presentation to the Obstetrical
Society, Little recited the lines from Richard III,
I that am curtailed of this fair proportion,
Cheated of feature by dissembling Nature,
Deform’d, unfinish’d, sent before my time
Into this breathing world, scarce half made up,
And that so lamely and unfashionable,
That dogs bark at me as I halt by them
(Shakespeare, Richard III, Act I, Scene 1) (Little 1861/1862, p. 343)

These few lines from William Shakespeare (1564–1616), Little thought, denoted
the clinical and pathological dimensions of cerebral diplegia. Little considered that
King Richard’s deformity from birth probably represented hemiplegia or other
palsy secondary to birth asphyxia. In this conclusion, he drew support from Sir
Thomas More’s (1478–1535) statement that at birth Richard was a breech presenta-
tion [“the feet forward” (p. 344)]. Richard III also was said to have been born pre-
maturely, being a difficult delivery and requiring resuscitation (Accardo 1980).
In a previous series of lectures “…deformities of the human frame,” Little had
written “… in many instances the spasmodic affection is produced at the moment of
birth or within a few hours or days of that event… The subjects were born at the
seventh month, or prior to the end of the eighth month of … gestation. In two cases
the birth occurred at the full period of gestation, but owing to the difficulty and
slowness of parturition the individuals were born in a state of asphyxia, resuscita-
tion having been obtained, at the expiration of two and four hours, through the
persevering efforts of the acoucheurs” (Little 1843/1844, p. 319). According to a
contemporary observer, the eighth and ninth lectures detailed “a peculiar distortion
which affects new-born children which has never been elsewhere described … the
spasmodic tetanus-like rigidity and distortion of the limbs of new-born infants
which… [he] has traced to asphyxia neonatorum, and mechanical injury to the foe-
tus immediately before or during parturition” (Anonymous 1854, p. 21). In this
early report, only in passing did Little describe spastic diplegia with greater involve-
ment of the lower extremities, among the several types of paralysis (Lecture IX).
82 5  Fetal Asphyxia and the Primate Colony in Puerto Rico

By the end of the nineteenth century, this was known widely as “Little’s Disease”
(Longo and Ashwal 1993; Schifrin and Longo 2000).
Probably the earliest study of the effects of hypoxia on the developing mammal
was the demonstration in 1670 by the distinguished English chemist Robert Boyle
that 1-day-old “Kitlings … continued 3 times longer in the Exhausted Receiver,
than other Animals of that bigness would probably have done” (Boyle 1670, p.
2019). As noted earlier, since the studies of Pflüger (1877), Zuntz (1877), Zweifel
(1876), many others have verified that fetal and newborn animals are more resistant
to hypoxemia than are adults (For instance see Dawes 1968, p. 141ff).

5.2  Eastman and “Mt. Everest In Utero”

As noted earlier, in the early 1930s in conjunction with his studies to understand the
genesis of asphyxia of the newborn infant, Nicholson Eastman explored several
aspects of maternal-to-fetal placental respiratory gas exchange. First, he attempted
to define the normal physiologic state and the role of hypoxia, hypercarbia, and/or
other factors in the initiation of respiration at birth. As background for these studies,
at this time there was little agreement on those factors that initiated newborn respi-
ration at the time of birth. Some attributed this to the sensory stimulation of the
process of delivery (for instance see Preyer 1885, p. 151ff). Eastman argued against
this, pointing out that attempts at version and/or the application of forceps to the
fetal head failed to initiate breathing. Others held that exposure to air and the change
in temperature were major stimuli. Again, Eastman pointed out that respiration
began as usual in those infants Ahlfeld had delivered with their mothers immersed
in a warm saline bath (Ahlfeld 1888). In a series of studies in which he measured
umbilical cord respiratory blood gases at birth, he concluded that for optimal man-
agement of asphyxia neonatorum, rather than administering CO2 or performing
physical stimulation, “… the chief therapeutic indication … is for oxygen (or air)
…” (Eastman 1932, p. 50). Importantly, Eastman believed, knowledge of respira-
tory blood gases could help to understand the genesis of asphyxia neonatorum
(Eastman 1930, 1932, 1936a, b; Eastman et al. 1933; Eastman and McLane 1931).
In a further study of anesthetic-induced causes of asphyxia neonatorum, Eastman
reported a rather startling human experiment (Eastman 1936a). To pregnant mothers
anesthetized with nitrous oxide (n = 28), chloroform (n = 4), or ether (n = 8) during
vaginal delivery or cesarean section, inspired O2 concentrations from 20 % to as low
as 5 % were given for 5–21 min. In association with light chloroform or ether anes-
thesia, fetal arterial and venous [HbO2] values were reduced only slightly, if at all.
When the women inspired a 20 % O2–80 % N2O mixture, umbilical venous and
arterial [HbO2] averaged 41 % and 22 %, respectively. Assuming pH values of 7.35
and 7.32, these saturations correspond to ~18 and 12 Torr, respectively. In seven
subjects who breathed 15 % O2, maternal [HbO2] averaged 79 % (PaO2 = 43  Torr),
while the umbilical venous and arterial [HbO2] values were 31 % and 15 %, respec-
tively, corresponding to PO2 values of 16 and 11 Torr, respectively. In three patients
5.2 Eastman and “Mt. Everest In Utero” 83

who breathed 10 % O2, maternal [HbO2] was 67 % (PaO2 = 33 Torr), and umbilical
venous [HbO2] and PO2 values were 12 % and 9 Torr, respectively. Two of these
mothers were slightly cyanotic, and the newborn infants showed evidence of
asphyxia. In seven subjects respired with 5 % O2 for up to 20 min, maternal [HbO2]
was 59 % (PaO2 = 29 Torr), and umbilical venous [HbO2] was 8.6 % (PO2 = 7  Torr).
The umbilical arteries of these latter infants were collapsed, presumably due to
circulatory failure with inadequate perfusion. All of these newborns were asphyxi-
ated: five were apneic for 5–25 min, and despite resuscitative efforts two died. Prior
to delivery, the hypoxemic fetuses had shown decreased respiratory movements in
utero. Eastman concluded by warning physicians of the extreme danger of using
<15 % inspired O2 in conjunction with nitrous oxide anesthesia (Eastman 1936a).
Although extreme by present day standards, it must be appreciated that in the mid-­
1930s, essentially nothing was known of the relation of maternal oxygenation or
anesthesia to the effects on the fetus-in-utero. Numerous subsequent reports have
shown a significant drop in fetal arterial O2 tension in concert with decreased maternal
arterial O2 tension (Longo 1987).
In another 1936 report, Eastman reviewed in extenso various aspects of asphyxia
neonatorum and others, summarizing in “Chart I” the critical changes in blood gas
and pH values (Eastman 1936b, p. 280). On the basis of earlier work that had dem-
onstrated decreased cardiac output as a consequence of asphyxia (Lewis and
Mathison 1910), Eastman posited that asphyxia pallida of the newborn was a con-
sequence of circulatory failure. He stated, “… that the one urgent need of asphyxi-
ated infants is oxygen…” He continued, “that the usual forms of stimulation
(including slapping, swinging, bathing, and carbon dioxide inhalation) produce
depression … and may even result in irreparable damage to brain cells” (Eastman
1936b, p. 297). As he had concluded previously, “The keynote of the treatment …
is gentleness – gentle removing of mucus from the respiratory passages and the
introduction of oxygen at gentle pressures. And in so far as this ideal has been real-
ized throughout, success will follow” (Eastman 1936b, p. 298). Two decades later,
in his 1953 Presidential Address to the American Association of Obstetricians,
Gynecologists, and Abdominal Surgeons, Eastman reviewed a number of aspects of
fetal oxygenation, comparing that state to “Mount Everest in Utero.” Emphasizing
the problem of cerebral palsy and other neurologic sequelae, he pointed out with
“… gratification and pride,” the record and accomplishments of clinical obstetrics.
He concluded, “But obstetrics must look to the future if it is to continue to serve the
best interests of our mother and children” (Eastman 1954, p. 711).
To consider anoxia and asphyxia in the newborn infant, Kenneth W. Cross
(Fig. 5.1b) of St. Mary’s Hospital, London, with Marcel Lelong (1892–1973) of the
University of Paris, and Clement A. Smith of the Boston Lying-in Hospital, orga-
nized a special symposium in London for six days in 1951 (Cross et al. 1953). Held
under the aegis of the World Health Organization’s Council for International
Organizations of Medical Scientists, the group of 17 clinical and basic science
leaders reviewed numerous aspects of newborn anoxia/asphyxia in terms of clin-
ical, histological and pathological, biochemical, physiopathological, and therapeutic
considerations. An important result of this conference was that it raised the
84 5  Fetal Asphyxia and the Primate Colony in Puerto Rico

consciousness of neonatologists and others and identified some strategies for

investigation of issues such as fetal/newborn anoxic tolerance, the mechanisms of
the initiation of respiration at birth, the status of the lung and brain at birth, factors
in adequate oxygenation, as well as the prevention and therapy of anoxia/asphyxia
(Cross et al. 1953).

5.3  W
 illiam F. Windle and the Primate Colony
at Cayo Santiago

Based on the studies of many authors, asphyxia, whether occurring ante-, intra-, or
post-partum, has been demonstrated to be one of the most potent factors altering the
course of brain development. Based on his series of lectures on “Developmental
Physiology,” William F. Windle, then at the University of Pennsylvania, brought
together into a small 70 page volume what was known and what was not known
regarding Asphyxia neonatorum …with special reference to its effect upon the brain
and subsequent clinical neurological manifestations (Windle 1950). With concern
for the relatively high incidence of stillbirths and neonatal deaths (Potter and Adair
1940), Windle asked “How greatly the number of such deaths can be reduced by
intelligent application of a knowledge of prenatal respiratory physiology …”
(Windle 1950, p. 53). In addition to addressing the problem of the number of indi-
viduals who suffer permanent damage to the central nervous system (Clifford 1941),
he spoke to the “… perhaps even more interesting problem … [of] possible impair-
ment of mental functions in individuals who were asphyxiated at birth but who
escaped clearly defined or persisting symptoms of brain damage” (Windle 1950,
p. 53). Windle then reviewed his studies in the guinea pig, chosen because a preg-
nancy included several fetuses, and the brains were of such size to allow multiple
serial section examination (Windle 1950, p. 55). Following asphyxiation for 4.5–
23 min, and then resuscitation for one-half hour or more (depending upon asphyxial
duration), regardless of the brevity of the insult, essentially all animals displayed
“… symptoms of a neurological nature after birth” (Windle 1950, p. 56). Windle
described both behavioral studies in a maze, and the associated neuropathological
findings, chiefly in the thalamic nuclei, geniculate bodies, tegmentum of the brain
stem, and cerebral cortex (Windle 1950, p. 59; see also Windle 1944; Windle and
Becker 1943; Windle et al. 1944). In addition to aspects of physiology of the fetus
and newborn, Windle reviewed other experimental studies of neurological, psycho-
logical, and neurohistological changes, particularly those in the guinea pig (Bailey
and Windle 1959; Windle and Becker 1943; Windle et al. 1944). After considering
the probable relation between asphyxiation in utero or during the neonatal period
with cerebral injury and neurological sequelae, Windle concluded considering the
analogous issues in humans, stating, “we are prone to blame inferior human men-
talities on poor environment or defects in the germ plasm.” He then asked, “Can it
be that asphyxia at birth is partly responsible?” (Windle 1950, p. 61).
5.3 William F. Windle and the Primate Colony at Cayo Santiago 85

In view of Dawes’ many studies and growing reputation in fetal oxygen con-
sumption and related matters, in 1959, Windle invited him to participate in his
studies of the effects of fetal asphyxia on the developing brain. An outstanding
neuroscientist, at this time Windle served as Chief of Neuroanatomical Sciences at
the National Institute of Neurological Diseases and Blindness (NINDB) within the
National Institutes of Mental Health at the National Institutes of Health (NIH) in
Bethesda, MD. He had led out in forming the Laboratory of Perinatal Physiology of
the NINDB within the NIH. As noted earlier, during the winter 1935–1936 Windle
had worked with Barcroft and had become intrigued with the antenatal genesis of
some neurological conditions (Windle and Barcroft 1938; Windle et al. 1938). To
understand better critical aspects of hypoxic-ischemic-induced brain damage in the
newborn, Windle with a group of collaborators worked to develop further an exist-
ing colony of Rhesus monkeys at the Cayo Santiago Field Station, a small island
just off the southeastern coast of Puerto Rico. This station had been founded in 1938
with a colony of free ranging rhesus monkeys to be used for behavioral, physiologi-
cal, and genetic research (Windle 1958, 1980). Here, they could have time-dated
pregnant animals for their studies (Jacobson and Windle 1960a; De Ramirez De
Arellano et al. 1959; Ranck and Windle 1959; Windle 1940, 1945) (Fig. 5.1c).
Windle has reviewed some aspects of these studies on the rhesus monkeys, including
the major brain regions involved, and comparison with findings in the guinea pig
(Windle 1960, 1961, 1963, 1967). He also detailed the establishment of this primate
colony, the vicissitudes of its maintenance both logistically and financially, and
work of the laboratory of Perinatal Physiology (Windle 1980). Other aspects of
Windle’s contributions have been presented (Clemente 1985).

5.4  The Puerto Rico Studies of Asphyxia

During the years 1959–1962, and also in 1966, Dawes and colleagues, some from
the NIMR, worked intermittently with Windle’s group (Fig. 5.2a). In light of Dawes’
interest in the basic physiologic aspects of clinical problems, he and his colleagues
had focused considerable attention to the problem of asphyxia of the fetus and new-
born infant, and the mechanisms by which the fetus was able to withstand prolonged
periods of hypoxia and asphyxia. In• an early study in sheep, Dawes had demon-
strated that fetal O2 consumption (VO2 ) per kg body weight remained relatively
constant during the last half of gestation, despite the great increase in its body
weight.
•
In addition, in both the fetus and newborn lamb a significant decrease in
VO2 occurred when arterial [HbO2] was reduced below 35 % (Acheson et al. 1957;
Cross et al. 1959; see also Dawes 1959). With Kenneth Cross and Joan Mott, Dawes
showed that, in contrast to adult sheep in which the rate of O2 consumption was
maintained when inspiring 6 % O2 (as contrasted with room air, •
20.9 % O2) and
cardiac output increased three- to fivefold, in the newborn lamb VO2 fell up to 40 %
with no significant increase in cardiac output. (Note: the latter already was near the
plateau of its cardiac function curve, Gilbert 1980). On the basis of inferior vena
86 5  Fetal Asphyxia and the Primate Colony in Puerto Rico

Fig. 5.2 (a) Dawes at the Primate Colony in Puerto Rico (ca. 1960). (b) L. Stanley James (1925–
1994). (c) Virginia Apgar (1909–1974)

cava blood flow, newborn O2 consumption appeared to decrease even more severely
in the lamb’s hindquarters
•
than in upper body. Cooling the lamb so that it began to
shiver, increased VO2 , and this shivering ceased upon breathing 10–20 % O2 (Cross
et al. 1959; see also Cross et al. 1953, 1954).
In one of his most highly cited papers, Dawes and colleagues explored the
role of glycogen in fetal and newborn cardiac function, and the relation of car-
diac carbohydrate concentration to survival in control and asphyxiated lambs,
5.4 The Puerto Rico Studies of Asphyxia 87

guinea pigs, rabbits, and rats (Dawes et al. 1959). Later, Joan Mott reviewed this
literature, showing the role of myocardial carbohydrate stores in survival times
for several species, at differing ages, ambient temperature, and with other vari-
ables (Mott 1961). A critical question regarding fetal asphyxia, was its effects on
cardiovascular reflexes and pulmonary vascular resistance. In the hypoxemic
lamb with [HbO2] <50 %, Dawes and Mott had shown that fetal O2 consumption
fell as blood lactate rose (Dawes and Mott 1959). He and colleagues also dem-
onstrated that perfusion of the pulmonary artery with arterialized blood from the
carotid artery reversed vasoconstriction associated with asphyxia, and this was
not altered by denervation. Dawes concluded that these responses were second-
ary to blood-borne hormones, with neural innervation playing little role (Cassin
et al. 1964a, b).
In their initial collaboration with Windle, Dawes and his group worked to obtain
physiologic data on monkey fetuses from 115 to 158 dpc (term = 168 days), and in
the newborns from birth to 12 days of age (Dawes et al. 1960, 1963a). In fetuses in
which they had catheterized the femoral artery (and in some cases the brachial or
carotid artery), they measured blood pressure and blood O2, glucose, and lactate
concentrations, reporting values similar to those of the sheep. They also showed that
oxyhemoglobin saturation in the blood to the upper body (brachial artery) was
~67 %, in contrast to that of lower body (femoral artery) of 58 % (Dawes et al.
1960). In addition, they determined that the fetal monkey weight doubled during the
last one-third of gestation, while that of the placenta did not increase significantly.
They also determined that on the basis of body weight the rate of fetal O2 consump-
tion was twice that of adult, but essentially the same as adult on the basis of body
surface area. In this study they demonstrated the presence of Hering–Breuer respira-
tory reflexes, and that vagal stimulation caused bradycardia. They also showed that
following umbilical cord ligation, gasping movements persisted for up to 20 min in
the fetus delivered abdominally, but only 7–8 min in those newborns that had been
delivered vaginally (Dawes et al. 1960). In related studies in fetal lambs, to establish
parameters for fetal survival following asphyxia, Dawes and colleagues studied
fetuses at 74–92 dpc (e.g., 0.5–0.7 gestation). In lambs asphyxiated by umbilical
cord ligation, infusion of both glucose and sodium bicarbonate resulted in blood
pressure, heart rate and arterial pH falling much more slowly than in those not so
treated, and survival was prolonged. Infusion of either glucose or alkali alone failed
to prevent these changes. These studies supported the idea that maintenance of
glycolysis helped to preserve cardiovascular function (Dawes et al. 1963b). At the
end of the experiments, they ligated the umbilical cord, and recorded the time to last
gasp, which decreased from 20+ min at 120 dpc to 10 min or less at term (~160 dpc).
These observations confirmed the much greater tolerance of the fetus to anoxia-
asphyxia, as compared to more mature animals (Adamsons et al. 1963; Dawes et al.
1963a), as had been reported in the lamb and other species (Dawes et al. 1963b;
Dawes and Mestyan 1963).
Subsequent to their determination of the fetal and newborn responses to asphyxia
in both lambs and rhesus monkeys, the group explored methods to alleviate the
inevitable adverse sequelae. Following delivery by hysterotomy, near-term fetuses
88 5  Fetal Asphyxia and the Primate Colony in Puerto Rico

of both species were asphyxiated by placing a rubber bag filled with warm saline
over their head and ligating the umbilical cord. In some fetuses, infusion of glucose
and alkali was initiated and continued for 1–6 min. “A short while” following the
last gasp the saline filled rubber bag over the head was removed, the trachea
­intubated, and resuscitation with oxygen commenced (Dawes et al. 1963a, p. 168).
Again, infusion of glucose and sodium carbonate was followed by prolonged
­maintenance of blood pressure and heart rate, with a greater success of resuscitation.
Although those lambs that received alkali–glucose infusion gasped significantly
longer than controls, and responded better to O2 insufflation, lambs failed to respond
as well as did the monkeys (Dawes et al. 1963a).
In a related study in near-term fetal monkeys delivered by hysterotomy, asphyxi-
ation was produced by umbilical cord occlusion following placement of a saline
filled bag over the head. Alkali and glucose infusion into the umbilical vein was
begun 6.5 min after the onset of asphyxia, and continued for 4 min. In monkeys so
treated, gasping continued longer and these animals were resuscitated more readily
upon ventilation with O2. Also in treated animals, the blood pressure was maintained
better than in untreated controls. These workers also determined that, although the
solution of sodium carbonate could result in hepatic hemorrhagic necrosis adjacent
to entry of the umbilical vein, infusion of trishydroxymethyl-­aminomethane
(Tris, with pH adjusted to 8.8) showed no such adverse effect (Adamsons et al.
1963). Thus, maintenance of normal blood pH values was found to prolong breathing
movements, facilitate resuscitation, and prevent brain damage.
In another study in Macaca mulatta, fetuses and newborns were asphyxiated by
being placed in a glass jar into which nitrogen flowed. Windle demonstrated that
while the fetuses could be resuscitated successfully as long as 7 min following their
last gasp, resuscitation of the newborns begun from 2 to 5 min after last gasp were
unsuccessful. Those infant monkeys that survived asphyxia with resuscitation, and
which were euthanized 10–13 days later, showed no central nervous system pathol-
ogy, as compared to the fetuses asphyxiated in utero that displayed symmetrical
focal destruction in the inferior colliculi. The authors speculated that this difference
in findings may have resulted from greater sensitivity of the more mature newborn
heart to the anoxic stress; so that these animals did not survive long enough for the
neuropathology to develop (Jacobson and Windle 1960a, b). In subsequent studies,
this group attempted to approximate more closely the circumstances of the human
infant, in which asphyxiation of the fetus during the latter stages of labor occurs
some time prior to the opportunity for treatment. In these instances, resuscitation
was more successful, and histological examination of the brains in the animals euth-
anized 6–26 weeks later disclosed a significant reduction in the incidence and extent
of damage in the brain stem and inferior colliculi (Dawes et al. 1964). In experi-
ments on asphyxiated Macaques, the Dawes group coined the term “primary apnea”
to describe failure to breathe soon after delivery, in contrast to “secondary apnea”
in prolonged asphyxia with development of acidemia, beyond the last spontaneous
gasp (Daniel et al. 1966b). Subsequently, a number of authors have explored
­physiological and biochemical aspects of fetal asphyxia and its sequelae (For
instance, see Jensen 1996; Jensen et al. 1999).
5.5 Virginia Apgar and Evaluation of the Newborn Infant 89

5.5  Virginia Apgar and Evaluation of the Newborn Infant

To develop, to a great extent as possible, a “model” of therapy of the asphyxiated

newborn, these workers combined positive pressure ventilation, a standard clinical
procedure in neonatal resuscitation, with intravenous glucose and alkali treatment.
The primate newborns delivered by cesarean section, were asphyxiated for
10–15 min, then ventilated with O2 while receiving an infusion of glucose–alkali.
The duration of time required to establish spontaneous respiration was markedly
reduced over that of newborns which were ventilated without combined therapy
(Adamsons et al. 1964). These studies also demonstrated in the monkey fetus the
correlation between the composition of blood samples from the scalp with carotid
artery or jugular vein blood (Adamsons et al. 1970). This would help to demonstrate
the validity of this technique for use in humans (Saling 1985).
Leonard Stanley James (1925–1994) (Fig. 5.2b) a Columbia University pediatri-
cian, and one of the founders of the specialty of neonatology, with Karlis Adamsons
Jr., an obstetrician gynecologist, and one of the founders of perinatology, continued
the studies on asphyxiated primates following their return to Columbia. There, they
collaborated with Virginia Apgar (1909–1974) (Fig. 5.2c), anesthesiologist and orig-
inator of the five point scoring system for neonatal well-being, Apgar had chosen the
criteria (Heart Rate, Respiratory Effort, Muscle Tone, Reflex Irritability, and Skin
Color), evaluated at 1 min, in part to obviate the need for intervention during attempts
at resuscitation of the newborn, holding that these functions could be determined
without compromising the infant’s care. Each variable was assigned a score of 0, 1,
2, with a total score of 10 indicating the most satisfactory condition (Apgar 1953).
Some have suggested that APGAR is an acronym for measuring: Appearance, Pulse,
Grimace, Activity, and Respiration. As a background of her studies, it is said that one
morning in the Columbia Medical Center cafeteria a medical student asked Apgar
how to evaluate properly a newborn infant. “That’s easy, you’d do it like this,” she
responded, writing down the five criteria listed. Then she rushed off to test this idea.
After examining this criteria on more than 1,000 newborns during 1950 and 1951,
she published her findings, and the rest is history (Calmes 1984). Stanley James has
recorded a somewhat different scenario of her idea noting that, as the former Chair
of Columbia’s Department of Anesthesiology, wishing to characterize an infant’s
condition at birth she completed a course in biostatistics offered by the School of
Public Health. She then chose the five signs classically used by anesthesiologists to
monitor a patient’s condition (James 1976). James noted,
She wished the score to be simple and easy to apply … to enable the physician or nurse to assess
the infant’s condition rapidly at a glance. She also recognized that time was important and made
her observations with a stopwatch which she carried around her neck.
(James 1976, p. 2)

James recalled further,

As with all of her projects, she approached this with great glee and enthusiasm, and mobi-
lized the interest of the obstetric and anesthesia services. She soon found that the obstetri-
90 5  Fetal Asphyxia and the Primate Colony in Puerto Rico

cians all wanted to score their babies 10. Some wished to give 12. From this she concluded
that it was important that some person other than the one responsible for the delivery should
make the score.
(James 1976, p. 3)

In a “second report,” Apgar and colleagues demonstrated that among 15,348

newborns studied, the death rate of those scoring 2 or less was 15 %, compared to
that for infants with a score of 10, which equaled only 0.13 % (Apgar et al. 1958).
Originally, the Apgar score was assigned only at 1 min. However, a 12 institution
“Collaborative Study of Cerebral Palsy, Mental Retardation and other Neurological
and Sensory Disorders of Infancy and Childhood,” which included over 17,000
newborns, presented evidence that repeated scoring at 5 min provided additional
prognostic information in predicting neonatal survival and neurologic development
(Drage et al. 1964). To a great extent, it was James and colleagues who attempted to
correlate the markers identified by Apgar with blood gas and acid–base values
(James 1985; James et al. 1958). Of clinical importance, these studies gave credence
to including the measurement of pH with that of blood gases, and administering
alkali, practices which have become standard. James has presented two relatively
brief reviews of Apgar’s accomplishments and contributions to life (James 1975,
1976). In explaining why she carried basic resuscitation equipment with her at all
times, Apgar is purported to have said, “Nobody, but nobody, is going to stop breath-
ing on me” (National Library of Medicine Profiles in Science, http://profiles.nlm.
nih.gov/CP/). And it has been said that, “every baby born in a hospital around the
world is looked at first through the eyes of Virginia Apgar” (Beck 2009).
In a reflection on the Apgar score, Geoffrey Dawes noted several important con-
tributions, namely that it required the student of the newborn to pay attention rap-
idly and critically to each of the five variables enumerated, its emphasis on the
importance of accurate timing of postnatal changes in the assessment of health, and
that it provided an easily understood semiquantitative estimate of the situation
(Dawes 1976). In his critique he noted that the score gives the same weight to
different variables, for instance, to changes in heart rate as to changes in color.
Nonetheless, he admitted that its universal adoption and continued application give
ample evidence of its practical utility and being an admirable pragmatic tool.
“Advances in technology have not displaced it, time has not impaired it and famil-
iarity has secured its position among the tools of neonatology” (Dawes 1976, p. 4).
As can be appreciated, these collaborative studies of basic scientists and clini-
cians, which used as experimental “models” both lambs and primates, resulted in a
number of contributions to understand more completely fetal asphyxia and acid
base balance, and suggest the optimal methods of treatment of human newborns
(Adamsons et al. 1963, 1964; Daniel et al. 1966a, b; Dawes et al. 1960, 1963a, c,
1964; James et al. 1958). Based, in part, on the work of Dawes, Windle, and col-
laborators, the pioneering neonatologist Robert Usher (1929–2006) at the Royal
Victoria Hospital and McGill University in Montreal, introduced the use of what
came to be called the “Usher regime,” consisting of intravenous sodium bicarbonate
solution with glucose and insulin to correct hyperkalemia and to maintain blood pH
References 91

within normal limits (Usher 1959). This reduced mortality in preterm infants by
about two-thirds (Usher 1961, 1963; and see below).
In a special issue of the British Medical Bulletin, Kenneth W. Cross reviewed in
extenso asphyxia neonatorum in terms of blood gas and pH values and the time
course of their changes, respiratory activity including “primary” and “secondary” or
“terminal” apnea, the time course of changes in heart rate and blood pressure in
association with intermittent positive pressure ventilation and neuronal activity. Of
particular value to the neonatologist, Cross detailed several criteria for effective
treatment (increase in heart rate, with return of gasping following reestablishment
of circulation), pointing out the problems with those that proved not to be effective
(Cross 1966).

5.6  In Summary

To a great extent, Windle remains the “unsung hero” of much of the work on
asphyxia of the fetus and newborn. It was the studies he initiated in the primate, in
collaboration with Stan James, Karlis Adamsons, Dawes, and others, that has led to
increased understanding of the pathophysiology of asphyxia and its sequelae in
terms of damage to the developing brain. In his 1968 monograph Foetal and
Neonatal Physiology…, Dawes included a chapter on “Birth asphyxia…,” in which
he summarized many of the studies by himself and others. Several of the figures
(such as Figure 69 that summarizes changes in fetal arterial blood gases and pH,
gasps per min, fetal heart rate, and arterial blood pressure in response to ~12 min
asphyxia followed by resuscitation; Dawes 1968, p. 149) have been widely repro-
duced in a number of volumes (Phibbs 2007).

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Chapter 6
The Pulmonary Vasculature and Dawes’
Foetal and Neonatal Physiology…

6.1 The Pulmonary Vasculature of the Fetus and Newborn

During the 1960s, Dawes with Sidney Cassin (1928–2010) (Fig. 6.1a), Joan Mott,
and other colleagues worked to understand the regulation of pulmonary vascular
tone and blood flow in the fetus, with the transition at birth to that of the newborn.
As noted earlier, Dawes appreciated that while the circulatory transitions at birth are
among the most profound at anytime during life, many of the studies reported previ-
ously were neither rigorous nor quantitative. Considering their importance, surpris-
ingly little was known concerning the quantitative aspects of these changes, or their
mechanisms. In a lengthy letter Sid Cassin composed a year before his death, he
described his initial interaction with Dr. Dawes and some of the early work of the
fetal pulmonary system. Because of the authority of this account, these remarks and
insights are given in length.
I first met Dr. Geoffrey Dawes in 1960 when he visited the Dept. of Physiology at the
University of Florida, College of Medicine in Gainesville, FL … to give a seminar on the
effects of hypoxia on the fetus and newborn. This was of particular interest to me since I had
studied the effects of anoxia on the newborn of several species as a doctoral candidate … at
the University of Texas Medical School in Galveston, Texas. After the seminar we had long
discussions on whether the heart or brain of the new born survived an anoxic insult better.
Of course we had different opinions and Dr. Dawes invited me to come to Oxford and work
in his research laboratory to resolve the problem. I finally made the trip with my wife and
four children (all under the age of seven) in 1962…
I was to study the appearance of cerebral oxidative enzymes during fetal maturation
using a Warburg apparatus and methodology. Although I managed to generate some data,
the approach was not very exciting, and experimental animals were difficult to obtain at
appropriate ages. Thus, I requested to work with Drs. Dawes, Mott, and Ross on the fetal
pulmonary circulation. The experiments were exciting and the team was outstanding. After
a meeting of the British Physiological Society where Dr. Dawes and Dr. Leonard Strang had
a heated discussion over Leonard’s presentation on the fetal pulmonary circulation, Strang
was invited to Oxford to see what Geoffrey was up to. As a result Leonard made the trip in
from London two or three times a week to participate in the research. I couldn’t have asked
for a more exciting and imaginative group of scientists with whom to spend a year…

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 97
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_6, © American Physiological Society 2013
Fig. 6.1 (a) Sidney Cassin (1928–2010). (b) Geoffrey Dawes; Vicky Arms Pub (Oxford, ca.
1975). (c) Title page (1968). (d) Geoffrey S. Dawes (ca. 1970)
6.1 The Pulmonary Vasculature of the Fetus and Newborn 99

The [sheep] laboratory itself, however, was quite a challenge. It was certainly not equipped
[in] the way my own lab back in the States … in the old Radcliffe Observatory, … Dawes’
work area was housed on the second floor. The windows were large and provided good
views of the Radcliffe Infirmary, but were not well insulated and in the winter (which was
described as the “worst winter in the last 100 years”) the cold came right through into the
lab. In addition the heating system was not efficient. Most of us ended up wearing heavy
winter clothing because of the low temperatures in the lab. Needless to say this made it
rather cumbersome to carry out some of the experimental techniques.
(Letter from SC to LDL, 19 September 2009)

Cassin described interactions between Dawes and NIMR Visiting Scientists.

In addition to the worst snow storm and cold weather … which we had to combat in order
to get into the lab, as well as the indoor temperatures, it is amazing to me now that we
accomplished as much as [we] did. The equipment available included an old Warburg and
Van Slyke apparatus as well as a very early model Severinghaus blood gas analyzer.
Computers were unheard of, and electrical calculators were not available. Ben Ross and I
spent many hours working out statistical regression analyses with the then state of the art
hand held Curta calculator. There were no elevators so pregnant sheep had to be pushed up
the circular stairway from the ground floor to the research lab. On the other hand we all
enjoyed the 10 AM and 3 PM tea held every day on the first floor, as well as our connection
with the Royal Oak Pub across the Woodstock road from the Nuffield. We all had charge
accounts at the pub which did not get paid but once every 3 months. On busy days with our
experiments a lunchtime pint of bitters and a half round (small sandwich) were much
appreciated. I would point out that Dr. Dawes performed all of the major surgery on the ewe
and fetus. His first assistant was Joan Mott and I was allowed to do simple surgical proce-
dures like the tracheotomy on the ewe, and [catheterized] the femoral artery and vein as
well as carotid artery and vein … on the ewe and the fetus. I also carried out analyses of
blood gas contents, pH, pO2 and pCO2 on the ewe and fetus. However, all of us seemed to
be having continuous discussions about the meaning of experiments, as well as how and
what to do next.
Whenever those discussions were at a standstill Geoffrey would invariably bring up
some current event or some topic he had recently read about in the London Times. None of
the rest of us had any knowledge of the topic and Geoffrey would grin and say “everybody
knows so and so, how come you do not”. At some point we decided to play the same game
with [him] … Leonard Strang found an obscure topic to read about in one of the London
papers and gave us all (except for Dawes) the reference. The next day Leonard asked about
the subject and each of us other than Dawes had a comment or two to make about the topic.
When we asked Dawes about it, he didn’t have a clue and looked very surprised. Well, we
didn’t let it go but kept pursuing his lack of knowledge of the topic. He apparently, got so
upset he had to pull out his inhaler to prevent an asthmatic attack. We then told him about
our scheme and he joined us in a bit of laughter. That evening after our experiment was
finished we all had a pint of bitters and a few scotch eggs together. However, it did put a
stop to Geoffrey’s daily irritating approach. He in turn, provided us with a dinner at his
house where he served us “jugged hare”, something I had never heard of before. This of
course was followed by a round of straight scotch malt (also new to me) and interesting
discussions.
Geoffrey’s wife Margaret was there and contributed greatly to our discussions. She was
unable to get involved to any large extent in the cooking because she was almost blind as a
result of retinitis pigmentosa. She did however provide an excellent dessert that evening
which was “orange syllabub”. However, Geoffrey was an excellent cook as well as a very
entertaining and delightful person. … At some point in our experimental work, Geoffrey
had to leave the Nuffield for an extended period in order to study the effect of asphyxia in
the fetal rhesus monkey with L.S. James. It was during this time and almost to the end of
100 6 The Pulmonary Vasculature and Dawes’ Foetal and Neonatal Physiology…

sheep season that Joan Mott and I did all of the fetal surgical procedures for our experiments.
This experience made it possible for me to carry on fetal pulmonary experiments when I
moved back to Gainesville…
(Letter from SC to LDL, 19 September 2009)

After reiterating some of the early work by Huggett, Barcroft, and others, Cassin
continued,
Dawes was not convinced that some of the studies which were reported prior to his inter-
est in the area were as quantitative as they should have been. Thus, in some of his early
work, [Dawes] and John Vane … developed what they labeled a “Density Flow Meter”
(Dawes et al. 1953a). With this device they were able to measure flows from 1 to
500 ml·min−1. In early studies by Ardran, Dawes … [and colleagues] (Ardran et al. 1952),
it was shown that ventilation of fetal lamb lungs produced a fall in pulmonary arterial
pressure. In other studies … it was shown that there was an increase in pulmonary blood
flow when lungs of fetal sheep and a fetal goat were ventilated (Reynolds et al. 1954).
However, there were no studies to show what happened to pulmonary vascular resistance
after ventilation. Thus, Dawes … carried out a series of studies on fetal sheep to measure
changes in pulmonary vascular resistance during ventilation (Dawes et al. 1953b). Not
only were measurements made of pulmonary arterial pressure and left atrial pressure, but
they were able to measure simultaneous flows… Using these techniques they demon-
strated decreases in pulmonary vascular resistance [increased pulmonary blood flow with
decreased pulmonary arterial pressure] when the lungs were expanded with air, oxygen,
[or] nitrogen. However, when the lungs were expanded with saline, pulmonary vascular
resistance increased (Dawes et al. 1953b). These studies resulted in further questions
concerning why there was a high fetal pulmonary vascular resistance, and the mecha-
nisms that were responsible for the decrease in pulmonary vascular resistance following
ventilation.
Prior to birth the fetal lungs are not effective organs of gas exchange … The fetal lungs
do, however, consume about 8 % of the total fetal oxygen consumption (Dawes et al. 1954)
as functions of growth and the process of lung liquid secretion (Adams 1966). Since the
pulmonary vascular resistance of the fetal lungs is quite high, most of the right ventricular
output goes through the ductus arteriosus to the descending aorta. In anesthetized, exterior-
ized fetal sheep close to term, blood flow through the lungs … was about 31 ml·kg−1·min−1
(Dawes et al. 1954) … [however], more recent studies on unanesthetized, catheterized fetal
sheep using radiolabelled microspheres provided flow rates which were higher (20 to
40 ml·kg−1·min−1) (Rudolph and Heymann 1974). Fetal sheep lungs ventilated with air,
oxygen or nitrogen showed a marked decrease in pulmonary arterial pressure as well as an
increase in flow … (Dawes et al. 1953b).
Other experiments on exteriorized fetal sheep demonstrated that using air instead of
nitrogen caused a greater decrease in pulmonary vascular resistance (Cook et al. 1963;
Dawes and Mott 1962) .… Addition of carbon dioxide to a ventilating gas mixture resulted
in pulmonary vascular constriction (Cook et al. 1963) … In 1962, [we] determined whether
inflation of fetal lungs with gas mixtures which cause little or no change in blood gas
would cause pulmonary vasodilation .… In our initial experiments we used a glass vertical
tube and noted that when blood sat in the tube for short times there was a dilator response
to blood entering the pulmonary circulation. This was bothersome, since we were not sure
of the cause of the dilation. Thus we changed to polyethylene tube and did not see the dila-
tion. [They also showed the integral role of O2 in the changes at birth. While ventilation
with N2 resulted in pulmonary vasodilatation, this was much greater with O2 ventilation]
(Cassin et al. 1964a). However, these events clearly stimulated Geoffrey to think about
glass and the production of vasodilators. Shortly after I left Oxford in 1963, I wrote to
6.1 The Pulmonary Vasculature of the Fetus and Newborn 101

Geoffrey about a former colleague and collaborator … at Columbia University [who] was
interested in the study of vasodilators. Dr. Dawes invited Anthony Manning Perks [later of
the University of British Columbia], to work at the Nuffield in 1964. Subsequently, Dawes,
Perks and a new group of visiting scientists were able to demonstrate that kinin formation
caused vasodilation in fetal sheep [pulmonary vascular bed] in which flow measurements
were made via an extracorporeal loop [with] glass tubes … (Campbell et al. 1968). In our
experiments, we filled the vertical polyethylene tube with blood, and allowed blood from
the tube to flow into the left pulmonary artery while carotid flow was temporarily stopped.
This permitted generation of pressure flow curves in which pressure was recorded on the x
axis and flow on the y axis of an XY recorder .… The curves were separated into a straight
upper portion and a curved small lower portion. Extending the straight upper portion of the
conductance curves allowed the estimation of the pressure intercept at zero flow. The con-
ductance are expressed as ml·min−1 or ml·min−1·kg−1. A relationship between arterial PO2
and PCO2 and conductance·kg−1 was derived by regression analyses .… The results indi-
cated that the more asphyxiated the fetal preparation, the lower the conductance. Also it
was established that unventilated fetal sheep had a lower conductance curve than those
ventilated with 7 % CO2 in N2. In fetal sheep at 138 days gestation, we found that ventila-
tion with 7 % CO2 in N2 had lower conductance curves than those ventilated with air or
with N2 only, but they were still greater than those derived in the fetal state. In additional
experiments in this series, we ventilated the fetal right upper lobes of the lungs, while
generating conductance curves of the left unventilated lung. Small increases of PO2 and
decreases in PCO2 caused substantial increases in the vascular conductance of the unventi-
lated lung. Similar pressure flow studies we carried out in immature fetal sheep (75–90
days gestation) indicated that pulmonary vascular resistance is elevated in mature fetuses
when compared to immature fetuses. [The studies also] demonstrated that acetylcholine
(2 μg) as well as isoprenaline (0.2 μg) caused markedly pulmonary vasodilation in the
immature fetus (Cassin et al. 1964b).
John “Jack” Thomas Reeves [(1928–2004)] also had the good fortune to work with …
Dawes … in 1967–1968 .… The studies demonstrated that in fetal sheep from 0.7 term on
exposed to hypoxemia, there was a rise in arterial pressure and femoral vasoconstriction.
These effects were eliminated following section of the vagi or aortic nerves, but were unaf-
fected by bilateral section of nerves from the carotid body and sinus (Dawes et al. 1969a).
They also demonstrated that sodium cyanide injection into both common carotids simulta-
neously produced a substantial cardiovascular response. In both cases (aortic and carotid
stimulation) there was an increase in arterial pressure (Dawes et al. 1969b). This was
thought to increase flow to the placenta and promote transport of oxygen to the fetus. Many
of the above described experiments led to further thoughts about the control of pulmonary
vascular tone, and the demonstration that other factors such vasoactive substances as well
as PO2 and PCO2 were involved in the regulation of pulmonary vascular resistance.
… rhythmical expansion of the lungs with gas mixtures that produced little or no change
in arterial blood oxygen or carbon dioxide produced pulmonary vasodilation. As a result
experiments we carried out to determine if the changes in pulmonary vascular resistance
were dependent on neural supply to the lungs and whether a single brief expansion of the
fetal lungs would result in the same decrease in pulmonary resistance as that seen with
rhythmical ventilation. It was established … that electrical stimulation of the peripheral
ends of the vagus on the same side as the pulmonary perfusion resulted in a vasodilation,
while sympathetic stimulation resulted in vasoconstriction of near term fetal sheep lungs.
This research group also demonstrated that after denervation of unventilated fetal sheep
lungs, acute hypoxia (by occlusion of the umbilical cord) would cause pulmonary vasocon-
striction (Colebatch et al. 1965). From these studies it was concluded that regulation of the
fetal pulmonary circulation in mature fetal sheep was partly controlled by the nervous sys-
tem, as well as by a variety of physiological and pharmacological influences, many of
which have been studied in detail.
102 6 The Pulmonary Vasculature and Dawes’ Foetal and Neonatal Physiology…

The basic mechanisms by which increased oxygenation or simple expansion of alveoli

with gases exert effects on the pulmonary vasculature are still not clearly established.
Alterations in PaO2, or simple dilation of alveoli may activate synthesis and/or release of
vasoactive materials such as prostaglandins, thromboxanes, prostacyclin, endothelins and
other substances (Cassin 1980, 1990a, b; Tod and Cassin 1997) …
(Letter from SC to LDL, 19 September 2009)

At the University of Colorado, “Jack” Reeves, to whom Cassin refers, went on to

collaborate with Robert F. Grover, and together they became leaders in cardiovascu-
lar physiology, and understanding the mechanisms that regulate components of the
oxygen transport system from the lungs to the tissues, particularly at high altitude
(Moore and Grover 2006; Reeves and Grover 2005).
In considering the contributions of others, Cassin continued,
Attempts have been made to localize the sites in fetal and neonatal lungs for [vascular resis-
tance] responses to ventilation, changes in blood gas tensions and drugs … The vasoactive
substance bradykinin causes a vasoconstriction of pulmonary veins, and vessels proximal
to the veins are passively distended in response to an increase in cardiac output (Hyman
1968) .… The Starling resistor model (a collapsible tube through which flow is related to
the pressure drop between inflow and surrounding pressure, as long as the surrounding
pressure is greater [than] outflow pressure), Raymond Dwight Gilbert applied to experi-
ments on the fetal lung. These studies … demonstrated … the average surrounding pressure
in the fetal goat lung [to be] about 21 mmHg. Upon ventilation of the lungs with fetal gas
(4 % O2 and 6 % CO2 in N2), this pressure drops to 16 mmHg, whereas when ventilation
occurs with air, it … dropped to about 13 mmHg (Gilbert et al. 1972, 1973). These values
are in accord with the shifts in intercepts of the pressure flow curves previously described
(Cassin et al. 1964a). The data support the concept of a high critical closing pressure in the
fetal lung, with recruitment of vessels accounting for the non linear pressure flow curves
and for much of the change in pulmonary flow with initiation of respiration .… Vascular
resistance proximal to the Starling Resistor was 4 to 5 times higher … than the resistance
distal to it .… When ventilated with fetal gas [those values fell about one-third] (Gilbert
et al. 1972). Still with all these studies the exact site of Starling Resistors in the pulmonary
vasculature is unknown. Indirect evidence suggests that they are in both pre and post capil-
laries .… Injection of bradykinin into the pulmonary artery of the unventilated fetal goat
resulted in a significant decrease in [these resistance values] (Gilbert et al. 1973).
Experiments involving aerosolization of prostaglandin E1 in newborn goats suggested that
major sites of action and inactivation of prostaglandins are found in the precapillary vessels.
If this applies to the unventilated fetus, then perhaps the proximal resistance, which is about
87 % of the total resistance across the lungs, is situated on the arterial side of the capillaries.
Distal resistance which is about 11 % of the total resistance, could be located in the venules.
Since PGE1 presented as an aerosol produces a small decrease in pulmonary vascular resis-
tance, it is probably due to the fact that PGE1 enters the pulmonary vasculature proximal to
the capillaries (Leffler et al. 1977, 1984).
(Letter from SC to LDL, 19 September 2009)

Elaborating further on these contributions Cassin recounted,

Early studies indicated that the fetal arterial carbon dioxide level varied with that of
maternal blood and is normally approximately 40 Torr. It was established that changes in
pulmonary blood flow following alterations in PaCO2 are large. Unfortunately, in these
experiments arterial pH was not maintained at a constant level (Cassin et al. 1964a; Cook
et al. 1963). However, Abe Rudolph with Yuan (1966) demonstrated that changes in CO2
may have been due to changes in pH. In carefully designed experiments in 4 newborn
6.1 The Pulmonary Vasculature of the Fetus and Newborn 103

calves they demonstrated that at a pO2 above 100 Torr, pulmonary vascular resistance
increased minimally as pH dropped from 7.39 to 7.18. In contrast when arterial pO2 was
reduced to below 40 Torr, pulmonary vascular resistance increased sharply over the same
range of pH values. Gilbert et al. (1972) studied the effects of PaO2 on calculated proximal
pulmonary vascular resistance using the Starling Resistor model and also the relationship
of PvO2 on distal resistance. Rp decreases until a PaO2 of about 40 Torr and then remains
constant. Similarly the distal resistance decreased as the PvO2 approached 40 Torr and then
remained constant (Gilbert et al. 1972).
The fetal pulmonary vasculature is not only reactive to changes in the blood gases but
also to many endogenous and exogenous vasoactive substances. Some of these have been
described above. Many body tissues synthesize, release, and metabolize prostaglandins.
A rather large source of prostaglandin (PG) production is found in the lungs (Pike 1971).
[In 1978, Cassin with colleagues demonstrated that indomethacin, a blocker of prostaglandin
production, did not alter the postnatal changes in the pulmonary circulation (Leffler et al.
1978). Others also showed that such PG inhibition failed to alter the pulmonary vasodilata-
tion caused by an increase in O2 (Morin et al. 1988)]. In 1978 Tyler and colleagues (1978)
carried out experiments to evaluate the effects of prostaglandin infusions as well as synthetic
analogues of endoperoxide intermediates into the perinatal pulmonary circulation.
Arachidonic acid and dihomo-γ-linolenic acid were used as precursors of mono and
bisenoic prostaglandins. Infusion of arachidonic acid into the pulmonary artery of fetal and
newborn goats produced an increase in pulmonary vascular resistance and a decrease in
systemic arterial pressure. With infusion of dihomo-γ-linolenic acid similar but less marked
results were obtained than with the arachidonic acid. Both of these precursors always pro-
duced dose-dependent increases in pulmonary vascular resistance in fetal and neonatal
goats and sheep. These results for arachidonic acid do not agree with responses seen in the
adult pulmonary circulation. Thus, while some investigators found that intrapulmonary
infusion of arachidonate in dogs (Hyman et al. 1977; Mullane et al. 1979; Wicks et al.
1976), cats (Hyman et al. 1977), and monkeys (Hyman et al. 1977) produced an increase in
pulmonary vascular resistance. To complicate matters further, either an increase or decrease
could occur in the feline pulmonary circulation following infusion of arachidonate (Hyman
et al. 1980). Those investigators noting an increase in pulmonary vascular resistance in
adults, suggested that since PGE2 and PGF2 increase in pulmonary venous blood, both
agents constrict the pulmonary vascular bed. In contrast those investigators noting a
decrease in pulmonary vascular resistance following arachidonate have suggested that this
is due to an increase in other prostaglandin like materials. PGD2, PGE1 and PGE2 are always
pulmonary vasodilators in fetal and neonatal goats and sheep. However, PGF1- and PGF2-
are always constrictors of the pulmonary circulation in these experimental animals. Thus,
the above described effects of arachidonate and dihomo-γ-linolenic acid may be due to a
release of the F series prostaglandins.
In terms of leuktrienes, these are produced from the same precursor fatty acids as the
prostaglandins, being derived from arachidonic acid via 51 lipoxygenase, rather than via
cyclooxygenase (Cassin 1990a, b). Saeed and Mitchell (1982) provided suggestive evi-
dence that lipoxygenase activity is present in human fetal lungs at 12 to 18 weeks of gesta-
tion. In addition leukotrienes (LTC4 and LTD4) have been found in lavage fluid of human
neonates with persistent pulmonary hypertension (Stenmark et al. 1983). In contrast fluid
from ventilated human neonates without pulmonary hypertension did not have these sub-
stances present. In neonatal lambs LTD4 is a powerful constrictor of both pulmonary and
systemic circulations (Yokochi et al. 1982).
Gause and coworkers (1988) reported on the effects of LTD4 and the putative [leukotri-
ene] end organ antagonist FPL 57231 on 24 fetal sheep that were delivered by Caesarean
section from chloralose anesthetized ewes. At constant pulmonary inflow, bolus injections
of LTD4 (0.1–10 μg) resulted in dose dependent increases in pulmonary vascular resistance.
FPL 57231 (1.0–10 μg kg−1) blocked the pressor responses to LTD4 and lowered normal
pulmonary vascular resistance in a dose dependent fashion. However, FPL 57231 also
104 6 The Pulmonary Vasculature and Dawes’ Foetal and Neonatal Physiology…

diminished the pulmonary pressor responses to U46619, a Thromboxane A2 mimic as well

as the pressor response to phenylephrine [hydrochloride]. Furthermore the pressor responses
to LTD4 were reduced by cyclooxygenase inhibition. In preliminary experiments it was
demonstrated that BW 755C (a phenidone derivative which is an inhibitor of both cyclo-
oxgenase and 5-lipoxygenase enzymes) did not block the pressor responses to hypoxia.
Thus, it appears that FPL 57231 decreases fetal pulmonary vascular resistance by non-
specific mechanisms. Also, the action of LTD4 is indirect and by way of the cyclo-oxygenase
system. Thus, although exogenous leukotrienes may produce marked pulmonary pressor
responses, endogenous leukotrienes are not likely to be responsible for the hypoxic pulmo-
nary pressor responses of fetal lungs or their normally high pulmonary vascular
resistance.
Studies concerned with the effect of cyclo-oxygenase inhibition on the pulmonary and
systemic circulations were carried out on normoxic and hypoxic premature (0.9 term) and
mature (1–14 days of age) goats (Tyler et al. 1975). Cyclo-oxygenase inhibition with either
indomethacin or meclofenamate increases the pressor response of the perinatal pulmonary
circulation to hypoxic insult. These data were important since indomethacin and meloge-
namate were used therapeutically to close the ductus arteriosus of preterm infants (Friedman
et al. 1976; Heymann et al. 1976) and to prevent premature labor (Wigvist et al. 1975;
Zuckerman et al. 1974).
Mechanical stretch or distension of adult lungs may result in their production of prosta-
glandins of the E series (Edmonds et al. 1969). Hyperventilation of cat lungs results in
production and release of PGI2 (Gryglewski et al. 1978). Thus it appeared to us that the
dilator prostaglandins could play a role in the normal decrease of pulmonary vascular resis-
tance during the transition from fetal liquid breathing to air breathing at birth. As a result
we investigated the effects of cyclo-oxygenase inhibition with indomethacin on the pulmo-
nary vasodilation that occurs with ventilation at birth. When fetal lungs are ventilated the
decrease in pulmonary vascular resistance occurs in two phases: 1) an initial rapid decline
that occurs within the first 30 seconds and is not affected by indomethacin, and 2) a slower
decline that is diminished by indomethacin and lasts 20 to 30 minutes (Cassin 1982). These
data support the hypothesis that the dilator substance (PGI2 and PGE2) may be involved in
the decrease on pulmonary vascular resistance in the transition from fetus to newborn.
(Letter from SC to LDL, 19 September 2009)

Cassin continued, considering the role of endothelium derived nitric oxide,

One of the most intensively studied mediators in the past 15 years is the endothelium
derived relaxing factor, which we now know is nitric oxide (NO) [(Amezcua et al. 1989;
Furchgott 1988; Ignarro et al. 1987)]. Synthesis and release of NO can be inhibited by
scavengers of NO (hemoglobin and superoxide anion) or inhibitors of guanylate cyclase
(methylene blue and LY-83583). Fetal and neonatal isolated pulmonary arteries and veins
synthesize NO and this activity increases with postnatal age (Abman et al. 1991; Steinhorn
et al. 1993).
(Letter from SC to LDL, 19 September 2009)

It should be noted that inhibition of NO synthesis prevents the postnatal increase

in O2-mediated pulmonary blood flow (Abman et al. 1990). Other studies demon-
strated the key role of NO in decreasing pulmonary vascular resistance in response
to air (20.9 % O2) ventilation or that with 100 % O2 (Cornfield et al. 1992). Also in
the chronically catheterized fetal lamb O2-mediated pulmonary vasodilatation was
markedly attenuated by blockade of NO synthesis (McQueston et al. 1993; Tiktinsky
and Morin 1993). Convincingly, O2 tension modulates NO production in fetal pul-
monary artery endothelial cells (Shaul and Wells 1994). As an aside, NO-induced
increases in cyclin guanosine 3′5′-monophosphate-dependent protein kinase
6.1 The Pulmonary Vasculature of the Fetus and Newborn 105

phosphorylates, therefore activating the large conductance calcium sensitive potas-

sium (KCa) channel resulting in blockade of the L-type Ca2+ channel and vasodilata-
tion (Archer et al. 1994; Bolotina et al. 1994). In summary these studies demonstrate
the critical role of NO-mediated in K+Ca channel activation in mediating the pulmo-
nary vasodilatation at birth (Cornfield 2010).
Cassin also considered the clinical implications of these studies.
Treatment of persistent pulmonary hypertension of the newborn with low dose inhaled
nitric oxide has received much attention and appears to be effective treatment of this disease
(For instance, see Kinsella et al. 1992, 1993; Roberts et al. 1992). Our group demonstrated
that inhaled nitric oxide may also be effective in the treatment of respiratory distress syn-
drome of prematurity, with improvements of ventilation/perfusion matching and decreased
intrapulmonary shunting (Skimming et al. 1995). We also demonstrated that in newborn
lambs inhaled nitric oxide can effectively reduce pulmonary hypertension from a variety of
causes at doses of 10 to 80 ppm (DeMarco et al. 1996).
(Letter from SC to LDL, 19 September 2009)

Again, this series of studies resulted in several of Dawes’ most highly cited
papers (Cassin et al. 1964a, b; Colebatch et al. 1965; Dawes 1962c, 1965, 1966a, b;
Dawes and Mott 1962). In measurements of blood flow by use of an electromag-
netic flowmeter in the perfused near-term fetal lamb lung, in which they injected
either acetylcholine (cholinergic agonist) or histamine (vasodilatation, and contrac-
tion of bronchial smooth muscle), Dawes and Mott established that the high pulmo-
nary vascular resistance was a consequence of inherent vascular tone, rather than by
contortion or kinking of the blood vessels. In the unexpanded lung, changing the
fetal [HbO2] by ventilating the ewe with either 100 % or 10 % O2 resulted in
decreased or increased pulmonary vascular resistance, respectively (Dawes and
Mott 1962). Further studies with Cassin of pulmonary arterial pressure versus flow,
established the dependence of pulmonary vascular resistance on arterial Po2 and
Pco2 values (flow decreased with low Po2 and high Pco2). Lung ventilation with
nitrogen resulted in a considerable decrease in pulmonary vascular resistance
(Cassin et al. 1964a).
In regard to these studies, Cassin speculated,
With the current emphasis on molecular biology and physiological genomics, examining
cellular mechanisms of ion channel activity in the developing pulmonary circulation could
lead to a better understanding of the regulation of high fetal pulmonary vascular resistance
and the events leading to low pulmonary vascular resistance in the postnatal period.
Regulation of the pulmonary circulation in the perinatal period involves extensive and com-
plex interactions of anatomic, mechanical, physical, and hormonal factors.
Although a number of these factors may contribute to the reduction in pulmonary vas-
cular resistance at birth, a single factor does not seem to be responsible for the high vascular
tone seen in the fetus, the maintenance of low vascular tone in the newborn, or the pulmo-
nary vascular response to hypoxia. Basic mechanisms of control of the perinatal circulation
continue to be researched actively. Hopefully this work will provide a better understanding
of the disorders associated with failure to achieve a dilated pulmonary vasculature at birth
as well as rational therapy for this problem.
(Letter from SC to LDL, 19 September 2009)

In 1969, Dawes summarized much of the work of the Nuffield Institute group in
regard to the pulmonary circulation of the fetus and newborn (Dawes 1969).
106 6 The Pulmonary Vasculature and Dawes’ Foetal and Neonatal Physiology…

6.2 Dawes’ Foetal and Neonatal Physiology…

In 1968 Dawes published his magnum opus on fetal and neonatal physiology. Some
have wondered regarding the circumstances of this undertaking. As noted earlier, in
1947 Dawes had spent several months at the University of Pennsylvania, at which
Julius Hiram Comroe Jr. (1911–1984) chaired the Department of Physiology in the
Graduate School of Medicine. As a consequence of their meeting and with mutual
interests, in the early 1950s Dawes and Comroe collaborated on a major review
“Chemoreflexes from the heart and lungs.” (As an aside, this paper includes essen-
tially nothing on the developmental chemo- or baro-receptor reflexes, Dawes and
Comroe 1954). Following Comroe’s move in 1957/1958 to the University of
California San Francisco, as first director of the newly established Cardiovascular
Research Institute (CVRI), he invited Dawes to spend a sabbatical leave in the
Institute to write a book. This Dawes did from April to December 1966. Under the
enlightened direction of Comroe, the CVRI included the crème de la crème of
investigators in cardiac, pulmonary, and vascular biology. Thus, during this sab-
batical, Dawes wrote what was to become his classic, Foetal and neonatal physi-
ology… (Dawes 1968) (Fig. 6.1c). To assist in this endeavor, Comroe provided an
editorial staff and medical illustrator. To further his knowledge of contemporary
clinical relevance, Dawes attended the weekly UCSF neonatal/perinatal confer-
ences “… where he was an imposing presence” (Phibbs 2007, e36). Dawes’ resulting
volume was published by Year Book Medical Publishers, the same firm that
published Comroe’s Physiology of Respiration (Comroe 1965).
Later, Dawes recorded that week by week he wrote the chapters for this mono-
graph, viz, “the comparative anatomy of the placenta,” “oxygen transfer across
the placenta,” “the placenta and foetal growth,” “maternal placental and myome-
trial blood flow,” “the umbilical circulation,” “the pulmonary circulation in the
foetus and newborn,” “the foetal circulation,” “foetal blood gas tensions and pH,”
and so forth; seventeen chapters in all. An appendix detailed experimental
methods such as the management of sheep for experimental studies, methods to
improve fetal accessibility, perfusion of the placenta, and the use of electromag-
netic flowmeters. Weekly, he would present his latest chapter to Comroe and
selected members of his staff for critique. As recounted by Sir Graham “Mont”
Liggins (1926–2010), “By the end of the meeting his chapter had been torn to
pieces. Lesser men would have been discouraged, but not Dawes, who would
return to the next meeting with an edited version and new chapter. The edited
chapter satisfied even the sternest critic. The book became the bible of foetal
physiologists” (Liggins 1998, p. 118). John Allen Clements, a member of the
CVRI faculty, has recalled that during this period,
He would draft a chapter in his rented apartment in Berkeley, send it to the CVRI, and then
meet with Julius [Comroe] and Bill Tooley and me for our critiques. Naturally, it was Julius
who had the most useful suggestions. It wasn't all work, though. We also shared dinners at
each others' homes, events that allowed Geoffrey's wife Margaret to shine. Although nearly
blind from retinitis pigmentosa, she was a brilliantly witty conversationalist. I will never
6.2 Dawes’ Foetal and Neonatal Physiology… 107

forget her declaiming in that quintessentially English voice and inflection, "Scientists are
like dirty little boys, forever peeking under Nature's skirts!"
Back then I found such thoughts hilarious, even exciting, but alas, they're only wistful
memories today.
(Letter from JAC to LDL, 1 May 2009)

In the Preface of his work, Dawes observed,

The Main Theme of this book is the development in the foetus and newborn of the inte-
grated responses which are needed to conserve their energy supply for maintenance of their
internal environment, growth and development. For some years it has been apparent that the
large and rapidly increasing literature in this field requires a more general treatment than is
possible within the scope of a review article. I have attempted to cover the main features of
the cardiovascular and respiratory systems, some relevant aspects of energy metabolism,
temperature control and growth, and their integration by hormonal and nervous mecha-
nisms. The evidence available is like an unfinished patchwork quilt, derived from many
species and incomplete in part. There are other aspects of the physiology of this period of
life which have been excluded … not because I think they are unimportant, but, because
they are peripheral to the main topic.
(Dawes 1968, p. 5)

In his introductory chapter, Dawes stressed the idea that of the many species
available for laboratory investigation, each has unique characteristics (such as
maternal nutrition, length of gestation, weight at birth, relative organ weights, blood
pressure, growth rate, maturity at birth) that present both a challenge and an oppor-
tunity to the investigator attempting to elucidate physiologic principles (Dawes
1968, pp. 13–17).
The work is truly a tour de force in synthesizing what was known, as well as
defining a number of problems for future study. Dawes is to be credited with quot-
ing widely from the literature, and in attempting to unravel controversial issues. For
the most part, the studies conducted in fetal sheep and other “models” were per-
formed in acutely anesthetized instrumented animals. Thus, although some of the
acute preparation studies remained valid, such as “centralization” of the circulation
in response to hypoxia (Campbell et al. 1967a, b), and vascular reflexes (Dawes
et al. 1968), others such as those on regulation of specific circulations such as the
umbilical (Dawes 1962a, b) required reconsideration. Nonetheless, as noted by one
reviewer,
Foetal and Neonatal Physiology is a thoughtful and thought-provoking book by an out-
standing investigator in the field. In each chapter the historic background is sketched, exper-
imental work is summarized and evaluated, and, in many instances, clinical experience is
integrated with the whole. I am impressed with the author’s fair-minded appraisals, not only
of others’ work, but of his own as well, and with the wealth of alternative interpretations
that he finds for observations. The book might have been subtitled “Perspicacity,
Perseverance, Pains, and Pitfalls in the Pursuit of Pantology.” The pitfalls are given special
attention and, with suitable selection and abridgment, another book might emerge: How Not
to Do Research.
(Chesley 1968, p. 615)

As the field of fetal and neonatal physiology has matured, Dawes’ synthesis has
received the encomiums of numerous investigators as a point of reference.
108 6 The Pulmonary Vasculature and Dawes’ Foetal and Neonatal Physiology…

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Chapter 7
Embryology and Early Developmental
Physiology

7.1 Origins

Knowledge of the normal developmental profile of embryo, fetus, and placenta is

necessary for understanding many aspects of fetal physiology. By the time of birth
the human newborn will have been transformed from a single cell 0.1 mm in diam-
eter and weighing less than 10−9 g to a creature with many millions of cells that
normally weighs ~3 kg. This miracle of development occurs over a period of 266
days following fertilization (or 280 days, 10 lunar months, from the onset of the last
menstrual period; Hamilton and Mossman 1972). Following fertilization, the
embryonic period extends through the eighth gestational week and this is followed
from the ninth week onward by the fetal period. Emergence of the embryo and fetus
involves the coordinated regulation of cell division with hyperplasia [increase in the
number of cells], hypertrophy [increase in the cell size], and cellular differentiation
under the orchestrated activity of thousands of genes, growth factors and other pro-
teins, and many factors probably yet to be discovered. Details of the many aspects
of embryonic/fetal development and its timing have been well described (Benirschke
1993; Hamilton et al. 1945; Hamilton and Mossman 1972; O’Rahilly and Müller
1992). A critical aspect of this developmental regulation are the cellular and molec-
ular signal transduction mechanisms by which the generation of different cell types,
their function and spatial organization, and ultimate form is realized. Not unexpect-
edly, there is some controversy regarding the degree to which we are approaching
an understanding in depth of these mechanisms (Wolpert 1994).
As is recognized, fetal and neonatal physiology has its origins in the study of
fertilization, embryology, and development. Embryology [Greek, inward folding],
the science that treats the formation of the embryo, has been of interest since earliest
times. Perhaps based, in part, from the study of bird embryos, ancient investigators
recognized the correct function of the placenta and umbilical cord. For example,
Aristotle (384–322 BCE), the first observational biologist and one time tutor to
Alexander the Great (356–323 BCE), in his great embryological treatises De gen-
eratione animalium [On the generation of animals] and De animalibus [of animals]

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 113
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_7, © American Physiological Society 2013
114 7 Embryology and Early Developmental Physiology

wrote at length on generation and classified animals on the basis of their embryo-
logical characteristics. Included in this first work is the report of his examination of
the developing chick on successive days of embryogenesis. Aristotle noted that the
umbilical vessels join the placenta and interior uterine wall in a manner similar to
the roots of plants, and through them the embryo receives its nourishment (Aristotle
1831–1870). The ancient investigators also recognized the similarities of early
development of birds and mammals. Along with the development of practical meth-
ods to incubate fertilized chicken eggs, this revelation led to the use of the develop-
ing chick as an important vertebrate model organism for embryological research
from that time forward.
It is of interest to speculate on embryologic research in ancient times. For exam-
ple, Rabbinic legend holds that Cleopatra VI (69–30 BCE) “… investigated the
process of foetal development by the dissection of slaves at known intervals of time
from conception, following the precepts of Hippocrates (460–375 BCE) with regard
to hen’s eggs” (Needham 1934, p. 47). Ancient Indian texts (ca. the sixth century
BCE) also demonstrate a relatively detailed knowledge of human embryology, and
knowledge in this area as “… likely to have passed in one direction to the other
[i.e., between Indian and the Mediterranean]” (Needham 1934, p. 2). Beginning in
the renaissance, a number of anatomists gave quite accurate accounts of morpho-
logic aspects of fetal development. For instance, the artist, engineer, polymath,
Leonardo da Vinci (1452–1519) contributed much to the embryology of mammals
and birds (da Vinci 1913), although his early sixteenth century drawings did not
come to public knowledge until two and a half centuries after his death (O’Malley
and Saunders, 1952). Giacomo Berengario da Carpi (ca. 1460–1530), professor of
Surgery at the University of Bologna, advocated the study of fetal development as
the tissues are simpler and less well developed than in the adult, and in some
instances only vestigial in the adult. Andreas Vesalius (1514–1564), the founder of
modern anatomy, in the second edition of the Fabrica… (Vesalius 1555) differenti-
ated the discoidal placenta of man, from the annular placenta in the dog, and the
cotyledonous placenta of ruminants. A pupil of Vesalius and discoverer of the pul-
monary circulation, Matteo Realdo Colombo (1510–1559) of the Universities of
Padua, Pisa, and then Rome in his De re anatomica… carefully described the pla-
centa which he first named (Colombo 1559). Gabriele Falloppio (1523–1562) in his
Observationes anatomica [anatomical observations] of 1561, noted that the human
fetus has a single umbilical vein, in contrast to two in ruminants (Falloppio 1561).
Giulio Cesare Aranzi [Arantius] in his De humano foetu was the first to maintain the
independent and separate placental maternal and fetal circulations, and that organ’s
ability to purify fetal blood (Aranzi 1564).
Volcher Coiter (1534–1576) in his Externarum et internarum… [of that that is
outside and inside]… described development of the chick embryo on 20 successive
days. Unfortunately, this account was not illustrated (Coïter 1572). Several other
investigators of this time detailed aspects of embryological development.
For instance, Girolamo Fabrizio (Fabricius de Aquapendente; 1533–1619) in his De
formato foetu (Fabrizio 1604) and De formatione ovi et pulli (Fabrizio 1621) and
Adrian van der Spieghel (1578–1625) (Spieghel 1626) illustrated development in a
7.1 Origins 115

classic manner. Nathaniel Highmore of Oxford, collaborated with William Harvey

in using an early microscope to detail many of its features (Highmore 1651a, b). Walter
Needham reported measurements of chemical constituents of the chick embryo and
several mammalian species, and gave detailed instructions on dissection techniques
(Needham 1667). Another who explored generation in the chick was the London
physician, and one of the original Fellows of the Royal Society, William Croone
(1633–1684). A preformationist and ovist, believing that a microscopic fetus existed
in the egg, Croone claimed to have found rudiments of the chick in the egg prior to
incubation (Cole 1944). Another of the preformationists, and one who contributed
greatly to the development of embryology as a science, was Marcello Malpighi who
presented the first accurate microscopical description of the chick embryo (Malpighi
1673a, b). In his five volume arbeit, Howard Bernhardt Adelmann (1898–1988) has
given the first English translation of Malpighi’s major works, as well as an authori-
tative treatise on the development of embryology (Adelmann 1966).
It was in the late seventeenth and eighteenth centuries, in the spirit of the new age
in science, that embryology became an experimental discipline. As noted earlier, it
was Regner de Graaf who first demonstrated ovulation, although what he believed
to be the ovum was the entire Graafian follicle (Graaf 1672). The same year, Jan
Swammerdam (1637–1680) reported similar findings (Swammerdam 1672). Several
decades later, Antonj van Leeuwenhoek (1632–1723) described the spermatozoa of
humans and other species, among his many other discoveries (Leeuwenhoek 1693–
1718). At this time, unable to explain how unique organs as the brain, heart, and
uterus could have arisen from a single cell during development, the idea of “prefor-
mation” (also called “predelineation” and “predetermination”; Needham 1934,
p. 213) held sway. According to this hypothesis, development occurred as a conse-
quence of unfolding and increase in size of organisms that preexisted within germ
cells, i.e., that all parts of the embryo and future organism exist completely formed
in the germ cell and develop only by increasing in size. The idea was held that
sperm contained a miniature human being. An illustration of this view is the 1694
illustration by Nicolas Hartsoeker (1656–1725) in his Essay de dioptrique, of a
miniature human within a sperm, a so called homunculus [diminutive of man]
(Fig. 7.1a) (Hartsoeker 1694, and see Gall 1996, pp. 24–25). Some even claimed
that the sperm of different species resembled the animals they were to form. This
contrasts with the concept of epigenesis; i.e., that an individual develops by struc-
tural elaboration from an unstructured egg, rather than by simple enlargement of a
preformed entity. This topic of disagreement is far beyond the scope of the present
essay (for an extended discussion, see Needham 1934).
As the field of embryological research matured, however, the concept of epigen-
esis (which originally had been advanced by Aristotle) with gradual and progressive
development from the fertilized egg containing the total pattern of the unborn indi-
vidual into specific organ structures, slowly was accepted. Working at the newly
established University of Göttingen, Albrecht von Haller (1708–1777) demon-
strated in both the chick embryo and human the rate of embryonic and fetal growth,
with the rate early in development being much greater than that near term (Haller
1758). Also at this time, in detailed studies of embryonic differentiation, Caspar
116 7 Embryology and Early Developmental Physiology

Fig. 7.1 (a) Homonculus (Hartsoeker 1694). (b) Stazione Zoologica Napoli (ca. 1880).
(c) Wilhelm Roux (1850–1924). (d) Ross Granville Harrison (1870–1959)

Friedrich Wolff (1733–1794) demonstrated the several organs developing in “leaf-

like” blastodermic layers, thus laying the foundation for the “germ-layer” theory of
Heinrich Christian Pander (1794–1865) (Pander 1817) and Carl Ernst von Baer
(Baer 1828–1888), to dispose of the concept of “preformation” (Wolff 1759). Also,
William Hunter (1718–1783) in his Gravid uterus (Hunter 1774) one of the finest
anatomical atlases ever published, presented a number of illustrations of the fetus
and placenta. Samuel Thomas Soemmerring (1755–1830) in his Icones embryonum
(Soemmerring 1799) included splendid engravings of late embryos and early
fetuses. Many other examples could be cited (Eskes and Longo 1993). Early in the
nineteenth century von Baer reported his monumental discovery of the mammalian
ovum (Baer 1827).
7.1 Origins 117

During the latter part of the nineteenth and early twentieth centuries biology was
transformed from a descriptive accounting of natural history, to a science dominated
by rigorous, quantitative experimental analysis. In a sense this was initiated by
Claude Bernard, who formulated the scientific method of investigation. (He also
compared glycogen metabolism in the fetal and adult liver; Bernard 1865). In addi-
tion, Hermann Vierordt (1853–1943) of the University of Tubingen, in his anatomi-
cal, physiological, and physical data and tables compiled an encyclopedic
compendium on anatomical characteristics, physiologic variables with composition
of various organs and tissues, and physical characteristics of the human at different
ages (Vierordt 1888). Up to this time, fertilization was poorly understood, and many
of the phenomenon of reproduction and embryology including chromosomes, mito-
sis, and other features had not yet been discovered. Jean Louis Prévost (1790–1850)
and Jean Baptiste Andre Dumas (1800–1884) in the frog first discovered that fertil-
ization occurs by union of spermatozoa and ovum (Prévost and Dumas 1824), while
Rudolph Albert von Kölliker (1817–1905) demonstrated the cellular origin of sper-
matozoa (Kölliker 1841). Martin Barry (1802–1855) of Edinburgh observed the
spermatozoan within an ovum (Barry 1843), and Wilhelm August Oscar Hertwig
(1849–1922) demonstrated not only that the spermatozoan enters the ovum, but that
fertilization occurs by union of the nuclei of the female and male sex cells (Hertwig
1876). Two decades later Robert Heinrich Johannes Sobotta (1869–1945) detailed
remarkably accurate illustrations of the steps involved in the generation of the
mouse embryo, commencing with the first divisions of the oöcyte and ending with
the first mitotic divisions of the embryo (Sobotta 1895).
In the scientific revolution of the late nineteenth and early twentieth centuries,
embryology was at the frontier of biological science. Critical to our understanding
of the development of embryology and its physiology is the growth in our knowl-
edge of genetics. These advances proceeded in several stages. Probably the earliest
of these was a concept of the German evolutionary biologist Friedrich Leopold
August Weismann (1834–1914), a graduate in medicine from Gottingen, who spent
most of his professional career at the Albert Ludwig University of Freiburg in
Breisgau. Weismann argued that two independent processes or cell types commence
with division of the fertilized egg. One type leads to formation of “soma” or cells of
the body, the other type, constitute cells of the “germ line,” the egg and sperm essen-
tial for initiation of the next generation. Union of these parent germ cells, he called
Amphimixis, which in his mind led not only to the development of a new being, but
constituted the principal source of heritable variation in evolution by natural selec-
tion (Weismann 1892a). The idea that genetic information cannot pass from “soma”
to “germ cell” and on to the next generation became known as the “Weismann bar-
rier” (Weismann 1892c).
In addition, Weismann performed experiments that negated the concept of the
French biologist and comparative anatomist Jean-Baptiste Pierre Antoine de Monet,
Chevalier de Lamarck (1774–1829), that organisms may inherit traits acquired dur-
ing their parent’s lifetime (Lamarck 1815–1822). For instance, to counter the
Lamarckian proposition that a giraffe’s neck elongated as it ate from the highest
leaves on a tree, and this change would persist in the next generation, Weismann
118 7 Embryology and Early Developmental Physiology

repeatedly chopped-off the tails of 1,500 rats over 20 generations. Among the over
900 offspring, no rat was born without a tail (Weismann 1892b). In its essence,
Weismann’s “germ plasma theory” stated that multicellular organisms consist of
germ cells that contain heritable information, while somatic cells contain the data to
conduct the functions of their particular cell type. Weismann’s work established that
heredity is dependent, not on a flow of matter or of energy, but of information.

7.2 Stazione Zoologica di Napoli

As noted earlier, in the late nineteenth century the German Universities were
preeminent in the support of scholarship in science, medicine, and many other
fields. In the scientific culture of this era, the sea was regarded as the origin of the
most elemental forms of life, and as a valuable source in the endless search for
knowledge. Marine organisms became a center of interest for naturalist followers of
Naturphilosophie [natural philosophy], many of whom searched the oceans for the
Urschleim [elementary living matter]. The new generation of biologists immersed
in this philosophy looked to the sea as a source of knowledge regarding fundamental
biological problems. In regards to the development of modern day embryology, a
major factor was establishment of, and contributions by, investigators at the Stazione
Zoologica di Napoli (SZN) in 1873–1874 (Fig. 7.1b). Following the Italian
Risorgimento [resurgence, reorganization] with the unification and creation of the
Italian State (which followed several wars of independence in the late 1850–1860s),
the spirit of nationalism and return to Principi fondamentali [fundamental princi-
ples] extended to support the arts and sciences. Biology at this time, was searching
for general laws, with attempts to synthesize embryology, phylogeny, and compara-
tive anatomy within the Darwinian paradigm of epistemology and natural selection.
Thus, the last several decades of the nineteenth and the first few decades of the
twentieth centuries, were the “golden age” of descriptive and comparative embry-
ology. The founder of the Stazione in 1872, Anton Dohrn (1840–1909), originally
from Pomerania (present day Poland), had trained in Jena with the morphologist
Ernst Heinrich Philipp August Haeckel (1834–1919), author of the proposed bio-
genic law “Ontogeny recapitulates phylogeny” (Haeckel 1868). Based on Haeckel’s
theory of recapitulation, comparative embryology was becoming the cornerstone of
morphology. With appreciation for the rich biological diversity of the Bay of Naples,
and with his family resources, in 1870 Dohrn commenced building the SZN at his
own expense. Presently the center is known as the Stazione Zoologica Anton Dohrn,
and its focus is on the biology of marine organisms.
The importance of the Stazione Zoologica extended far beyond its purely scien-
tific contributions. Renowned for its support of the arts and humanistic values, for
zoologists and other natural scientists the “Naples experience” consisted of a mix-
ture of scientific investigation, the acquisition of state-of-the-art methodologies, and
cultural enrichment. To establish this as a unique and world-renowned resource,
Dohrn made available the finest scientific instruments, equipment, and core
7.2 Stazione Zoologica di Napoli 119

laboratory facilities. To promote its international status, and to help ensure its
financial stability, Dohrn inaugurated innovations such as a “table or bench” system
in which investigators/institutions rented space for research. Each of the 30 or so
individual tables had an accompanying set of cupboards and shelves for chemical
reagents, histologic stains, and related materials. In addition, the Stazione employed
a technical staff who, not only obtained marine specimens for the investigators, but
also prepared and supplied such specimens to various universities, museums, and
other academic institutions. Additionally, Dohrn included in the Stazione a large
aquarium open to the public and founded several scientific journals. In contrast to
most Universities, the Stazione guaranteed independence of scientific pursuits, free-
dom from teaching, and the opportunity to interact with investigators from all over
the world. In its first three decades of existence, more than 2,000 investigators from
around the globe worked at the Stazione. Several writers have presented an analysis
of the Stazione Zoologica, its origin, role in biological research and the develop-
ment of embryology, and its continued role in science, art, and culture to the end of
the twentieth century (Fantini 2000; Monroy and Groeben 1985; Morgan 1896;
Müller 1996; Whitman 1883).
One of the early major discoveries at the SZN was that of Wilhelm August Oscar
Hertwig (1849–1922), who in the sea urchin egg established that fertilization
requires union of the nuclei of the male and female sex cells (Hertwig 1876).
Because the sea urchin sheds large translucent ova which can be maintained in fresh
sea water, this led to a number of vital studies in fertilization and early embryonic
development. Among the many scientists who worked at the SZN, and who were
stimulated by Hertwig, was Otto Heinrich Warburg (1883–1970) of Heidelberg and
Berlin. Between 1908 and 1914, Warburg used his “Warburg apparatus” (a modifi-
cation on the Haldane–Barcroft blood gas manometer) to study metabolism in the
eggs of the sea urchin. Importantly, he discovered a major increase in oxygen con-
sumption following fertilization and during cell division (Warburg 1908). Warburg
also discovered the essential role of an iron containing pigment in “cell respiration”
a term he coined, which led him to discover the function of a respiratory enzyme
(Warburg and Negelein 1929). Later, this was shown by David Keilin (1887–1963)
to be cytochrome oxidase (Keilin 1929). Warburg also described anaerobic glyco-
lytic metabolism, as occurs in many cancer cells (Warburg et al. 1924). In recogni-
tion of his numerous contributions, Warburg was awarded the 1931 Nobel Prize in
Physiology or Medicine.
Among the early American biologists to work at the Stazione Zoologica, was
Charles Otis Whitman (1842–1910), who became interested in the “program of
development,” and performed classic studies in establishing the analysis of cell-
lineage. These studies contributed additional evidence to support the concept of
“epigenesis,” and lay to rest that of “preformation” (Whitman 1878, 1894). Of note,
upon returning to the U.S.A., as curator of the Zoological Museum of the University
of Chicago, Whitman played a major role in establishing in 1888 the Marine
Biological Laboratory at Woods Hole, MA. Here he became its founding director,
continuing for two decades (to 1908), and enlarging his leadership in embryological
120 7 Embryology and Early Developmental Physiology

research (Maienschein 1978; Monroy and Groeben 1985; Whitman 1883). Whitman
was a member of the National Academy of Sciences, the Linnean Society of
London, and other prestigious societies (Morse 1912).

7.3 The Discovery of Genetics

Another leader who worked at the Stazione was Edmund Beecher Wilson (1856–
1939), of Columbia University, New York. Credited as being one of the founders of
the fields of cell biology and cytogenesis, Wilson stressed the importance of cyto-
logical structure and the central role of the nucleus in progressive cell development.
In his studies of experimental embryology and heredity, he was consumed by the
problem of how an entire individual may lie implicit in a single cell, and he explored
factors that result in cell segregation into tissues and organs with their functional
specialization. In his study of the cell-lineage of the marine work Neresis, Wilson
traced egg cleavage step-by-step through the formation of germ layers in the prin-
cipal embryonic organs (Wilson 1892). His work also established the idea that the
mosaic-like character of ontogeny emerges at early stages at different periods in the
several species (Wilson 1894), and with fate maps he followed embryonic
cell-by-cell development to establish the normal morphogenic processes from fer-
tilization onward (Wilson 1904). In his An atlas of the fertilization and karyokinesis
of the ovum…, Wilson was the first to produce clear photographic illustrations of
the early history of the fertilized ovum, that of eggs of the sea-urchin Toxopneustes
variegates enlarged about 1,000 diameters (Wilson 1895). He obtained recognition
for his The cell in development and inheritance (Wilson 1896), which, with critical
observations and analysis, laid the foundation for the study of the cell, and
understanding its structure and functions. Another of his monographs which
became a classic was The Cell in Development and Heredity (Wilson 1925). Wilson
made a number of other lasting contributions to both embryology and genetics.
For instance, he promoted the idea that the nucleus contains the basis of inheritance,
with chromatin as a key element of information, and with chromosomes containing
the “factors” or “genes.” He also discovered the X–Y chromosome system of sex
determination (Wilson 1905, 1906, 1914), detailing aspects of gene activation
(Lyon 1961), which still are under investigation. Another of the SZN investigators
who, by their study of chromosomal preparations from sea urchins and other
creatures, contributed greatly to this field was Walter Stanborough Sutton (1877–
1916), who advanced the idea that “hereditary particles” responsible for Mendelian
inheritance were carried by the chromosomes (Sutton 1903).
In 1900, Gregor Johann Mendel’s (1822–1884) laws of segregation and of inde-
pendent assortment or “ratios” in genetic inheritance (Mendel 1886), were rediscov-
ered independently by Carl Franz Joseph Erich Correns (1864–1933) (Correns
1900), Hugo Marie de Vries (1848–1935) (Vries 1900), and Erich Tschermak von
Seysenegg (1871–1962) (Tschermak 1900). Mendel, an Austrian monk and head of
a monastery in Moravia (former province of central Czechoslovakia), had trained in
7.3 The Discovery of Genetics 121

the physical sciences. In addition to his work with peas and their physical character-
istics, Mendel studied characteristics in several generations of mice, concluding that
they occur in fixed ratios. This discovery was critical in helping to illuminate the
fundamental discoveries and concepts of Weismann, Wilson, and others on the basis
of inheritance, and served as a foundation for modern genetics.
In the 1880s, Wilhelm Roux (1850–1924) (Fig. 7.1c), a pioneer experimental
embryologist in Breslau (now Wroclaw) and later the University of Halle, by inter-
fering with developing blastocysts from frog eggs developed the idea of
Entwicklungsmechanik [developmental mechanics] and raised questions with
respect to the developmental forces responsible for determining the planes of sym-
metry, and what after would be called functional adaptation (Roux 1888). Roux also
first established principles and techniques of tissue culture. Although some of his
ideas of the “mosaic” theory of embryonic development later were refuted
(Hamburger 1997), his demonstration that the nucleus of each blastomere is capable
of directing a specific independent line of differentiation, and that the nucleus con-
tains hereditary particles has remained valid (Oppenheimer 1967). Roux raised a
number of important questions regarding embryonic development, and played a key
role in moving embryology from a descriptive science to one of experimentation.
Also in this era, the Johns Hopkins embryologist William Keith Brooks (1848–
1908) was exploring fundamental questions regarding embryonic development. In a
two part Science essay, he posed a number of questions including that of, “Is cell-
differentiation inherent or induced?” (Brooks 1902a, b).
A thoughtful and distinguished naturalist tells us that while the differentiation of the cells
which arise from the egg is sometimes inherent in the egg, and sometimes induced by the
conditions of development, it is more commonly mixed; but may it not be the mind of the
embryologist, and not the natural world, that is mixed? Science does not deal in compro-
mises, but in discoveries. When we say the development of the egg is inherent, must we not
also say what are the relations with reference to which it is inherent? When we say it is
induced, must we not also say what are the relations with reference to which it is induced?
Is there any way to find this out except scientific discovery?
(Brooks 1902b, pp. 490–491)

One of Brooks’ graduate students, Ross Granville Harrison (1870–1959)

(Fig. 7.1d), went on to a distinguished career at Yale, pursuing developmental ques-
tions by definitive experiments. “Harrison’s gift was an ability both to frame the
questions and to devise ways and means of enticing the embryo to answer them
unequivocally” (Oppenheimer 1967, p. 93). Performing much of his early work in
Bonn, Germany, then the intellectual mecca for experimental embryology, Harrison
advanced techniques for tissue culture. By grafting frog embryos he created chimeras
to explore questions relating to the factors responsible for establishing bilateral
symmetry in development (Harrison 1907). Among his many contributions,
Harrison also helped to establish the mechanisms by which nerve fibers develop
(Harrison 1907, 1910). Recipient of numerous honorary degrees and other awards,
he was a member of the National Academy of Sciences and a foreign member of
the Royal Society. Following retirement, he chaired the National Research Council
(1938–1946), serving as an advisor to the government on many issues (Abercrombie
1961; Nicholas 1960; Oppenheimer 1967).
122 7 Embryology and Early Developmental Physiology

It was during this period that a Danish plant physiologist and one of the founders
of genetics, Wilhelm Ludvig Johannsen (1857–1927) of the University of
Copenhagen, coined the term “gene” as a unit of heredity. With the use of quantita-
tive accounting, Johannsen also made a fundamental contribution to biology when
he distinguished clearly between the view of the hereditary constitution of an organ-
ism and the totality of its genes, the “genotype,” and its appearance and function,
the “phenotype” (Churchill 1974; Falk 1984). In inbred “pure lines” of peas, beans,
and other plants, he also demonstrated a normal distribution of pod sizes, e.g., the
existence of two types of variability, that which was heritable (genetic) and non-
heritable (now classed as epigenetic) (Johannsen 1905, 1909). His underappreci-
ated conclusion was that identical genotypes do not necessarily produce identical
phenotypes. Johannsen has been viewed “… as a bridge over which nineteenth
century ideas of heredity … passed to be incorporated … into modern genetics …”
(Dunn 1973, p. 115).
Prior to his monumental studies in the fruit fly Drosophila melanogaster [dark-
bellied dew lover] at the turn of the century, Wilson’s Columbia University col-
league, the experimental zoologist and embryologist Thomas Hunt Morgan
(1866–1945) (Fig. 7.2b), also had worked at the Stazione Zoologica. By studies in
his Columbia “Fly Room” laboratory in which Drosophila mutations were created,
Morgan demonstrated that genes are carried on chromosomes, and are the basis of
inheritance. This discovery played a critical role in integrating the tenets of
Mendelian genetics and chromosomal inheritance into the field of contemporary
experimental genetics. The fly’s rapid breeding time and its four large chromo-
somes, made it an ideal “model” for examining the manner in which chromosomal
events during meiosis and mitosis determine structural features of the adult. A
serendipitous finding of a fly with a white eye (rather than the usual red) led Morgan
to appreciate the importance of the sex chromosome in many aspects of develop-
ment (Morgan 1926; Morgan et al. 1915). Despite some controversy regarding the
physical nature of the gene and certain aspects of Mendelian inheritance, genetic
research extended to other organisms, and the Entwicklungsmechanik [mechanistic
experimental approach] dominated genetics/embryology. For several decades,
Morgan, with his “boys” Colin Blackman Bridges (1889–1938), Hermann Joseph
Muller (1890–1967) (Fig. 7.2d), Alfred Henry Sturtevant (1891–1970), and others,
worked in the Fly Room to integrate Mendelism with the chromosome theory.
Among other projects, this involved the mapping of chromosomes, the discovery of
sex linkage, chromosome inversions, non disjunction, and other phenomena that
serve as the basis for understanding transmission genetics (Bridges 1913; Morgan
1910, 1911; Sturtevant 1913).
To a great extent, modern day genetics is founded upon much of the work and
ideas of Wilson, Johannsen, Morgan, Muller, and their colleagues. Each was a
member of the U.S. National Academy of Sciences. In 1913, Wilson served as pres-
ident of the American Association for the Advancement of Science, and in 1933
Morgan was awarded the Nobel Prize in Physiology or Medicine for discoveries
concerning the role of the chromosome in heredity (Allen 1976; Morgan 1939,
1941, 1942; Sturtevant 1959).
7.3 The Discovery of Genetics 123

Fig. 7.2 (a) Charles Sedgwick Minot (1852–1914). (b) Thomas Hunt Morgan (1866–1945).
(c) Hans Spemann (1869–1941). (d) Hermann Joseph Muller (1890–1967)

Among the young stars in the galaxy that surrounded Morgan was Hermann
Muller, who later moved to the University of Texas, Austin. With colleagues,
Muller studied the rates of natural gene mutation in Drosophila. In the course of
these investigations, they recorded the first induction of a genetic mutation, that of
increasing the mutation rate several-fold upon exposure to X-rays (even diagnostic
X-rays not being innocuous in this regard; Muller 1927). In 1946, Muller was
awarded the Nobel Prize in Physiology or Medicine “for discovery of mutations by
124 7 Embryology and Early Developmental Physiology

means of x-ray irradiation.” With his insights into the dangers of the over-use of
radiation exposure in diagnostic radiology, and of the nuclear arms race, Muller
became a severe critic of the U.S. policy of testing and using nuclear weapons
(Muller et al. 1947).

7.4 Embryology Becomes a Science

In the late nineteenth century, Charles Sedgwick Minot (1852–1914) (Fig. 7.2a),
lecturer in embryology and later James Stillman Professor of Comparative Anatomy
of Harvard Medical School, amassed a superb collection of embryological material.
Also during this period, he invented the automatic rotary microtome for cutting
ultra-thin tissue sections for detailed morphological analysis. Cutting the embryos
into serial sections, and arranging them in steel cabinets, this collection grew into an
unrivaled resource for teaching and research (Councilman 1918). His Human
Embryology, a work of over 800 pages on which he spent a decade writing, pre-
sented a comprehensive summary of issues regarding human development, with the
introduction of several novel theories (Minot 1892). Soon thereafter he introduced
the term “cytomorphosis” to describe the structural alterations cells undergo during
the course of their development (Councilman 1918; Minot 1908).
Several decades later, a work by Franz Karl Julius Keibel (1861–1929) and
Franklin Paine Mall (1862–1917), both students of the embryologist Wilhelm His
(1831–1904), expanded upon His’ monumental Anatomie… of human embryology
(His 1880–1885, Keibel and Mall 1910–1912). An exhaustive, encyclopedic work,
it was said to “… mark an epoch of accomplishment in the study of human embry-
ology,” and at the same time furnishing “… exceptionally numerous suggestions of
many problems yet to be solved, with the most promising lines of attack” (Knower
1911, p. 493). Published simultaneously in German and English, the work illus-
trates the close relationships of investigators on both sides of the Atlantic that
trained under, or were otherwise influenced by, His. Keibel, who became lecturer at
the University of Freiburg, and later at the Universities of Strasburg, Königsberg,
and Berlin, contributed numerous morphologic studies in vertebrate embryology.
He is particularly noted for his Normentafeln zur Entwicklungsgeschichte… (1897–
1911), an encyclopedic survey of the embryonic anatomy of various vertebrates.
He also contributed to an understanding of many specific aspects of development,
such as that of the head, and various germ layers (Keibel and Elze 1908).
Mall, a graduate of the University of Michigan School of Medicine (1883),
obtained postdoctoral training in Leipzig under His and Carl Ludwig. With the
opening of the Johns Hopkins University School of Medicine in 1893, Mall became
the first professor of anatomy, where he continued to make a number of contribu-
tions to embryology (Mall et al. 1900–1908). At the Johns Hopkins, Mall helped to
make the study of anatomy an independent science of its own, and a vital part of
medical education. In 1914, he became the first director of the Department of
Embryology of the Carnegie Institution of Washington, to which he contributed his
7.4 Embryology Becomes a Science 125

extensive collection of human embryos. In addition to his numerous contributions

to anatomy and embryology, Mall was an important teacher and mentor to many of
the outstanding anatomists in the USA, and played a critical role in development of
the full-time system of educators in medicine.
Another who laid important groundwork in scientific embryology was Richard
Assheton (1863–1915) of Trinity College, Cambridge and lecturer at Guy’s Hospital,
University of London. Concentrating chiefly on mammalian (but also considering
other species’ embryonic growth in length), Assheton in his Growth in length;
embryological essays, concluded this to be determined by two centers of cellular
activity, e.g., that of the “… protoplasmic centre of the fertilized egg …” and the
“… centre … in the middle of the blastopore …” (Assheton 1916, p. 24).
Because of limitations in the available technology and methodology of this era,
experimental embryology was characterized by descriptions of morphological
changes with time, and with postulates such as “continuous fields,” “gradients,”
“inducers,” and “polarities.” A seminal concept that originated at this time was
that of a chemical “organizer” responsible for embryological development. This
gave rise to a large body of work aimed at discovering the biochemical substances
that accounted for morphologic development and progressive growth. One of the
pioneers in this line of investigation was Hans Spemann (1869–1941) (Fig. 7.2c) of
Rostock, Germany, and later Director of the University of Freiburg. Spemann’s
studies using microdissection in newt embryos focused attention on the signaling
properties of a group of embryonic cells they termed the “organizer” or “organizer
centers” that controlled morphogenesis in development (Spemann and Mangold
1924). In consideration of the formation of the formation of the eye of a frog,
Spemann mused,
How is it that the lens begins to grow just at that spot in the epidermis where it is touched
by the optic cup and exactly at that moment when the rudiment of the retina invaginates?
Do these processes mutually influence each other, either in that the growing lens presses the
retina inward or at least causes it to invaginate, or that the retina, while drawing in, starts the
growth of the lens? Or do both processes go on independently of each other in self-
differentiation of their respective rudiments, and does their exact fitting together depend
upon previous and accurate tuning of the parts to a perfect harmony between them?
(Spemann 1938, p. 44)

For much of the past century, the identification of the organizer’s neural inducing
signals has been viewed as one of the most important topics in early neural develop-
ment. For his work in chemical organizers in embryonic induction, Spemann was
awarded the Nobel Prize in 1935. Shortly thereafter, a vital contribution was that of
Oswald Theodore Avery (1877–1955) and colleagues at the Rockefeller Institute
Hospital, who with rigorous experiments in several types of pneumococcus bacte-
ria, established that DNA was the “transforming principle” in Mendelian genetic
inheritance (Avery et al. 1944; Kay 1970). It was the 1953 discovery of the molecu-
lar structure of DNA by James Dewey Watson and Francis Harry Compton Crick
(1916–2004) of the MRC Laboratory at Cambridge (Watson and Crick 1953a), their
proposal of the mechanism by which cellular DNA passed on their characteristics,
e.g., information with precision (Watson and Crick 1953b), and the manner in which
126 7 Embryology and Early Developmental Physiology

DNA codons in specifying amino acids and their sequence in proteins (Crick et al.
1961), that transformed genetics and biology. In 1962 Watson and Crick shared the
Nobel Prize in Physiology or Medicine with Maurice Hugh Frederick Wilkins
(1916–2004) of King’s College, London.
In addition to genetics and beyond the phenomenology of descriptive morphol-
ogy, Morgan was a pioneer in the study of chemical embryology (Morgan 1897,
1907, 1915). He advanced the field by treating development as a system in which
reactions could be measured by physical and chemical standards and interpreted
in terms of their interrelations. Eloquently, he presented his philosophy of
embryology.
A transparent egg as it develops is one of the most fascinating objects in the world of living
beings. The continuous change in form that takes place from hour to hour puzzles us by its
very simplicity. The geometric patterns that present themselves at every turn invite mathe-
matical analyses. The constancy and orderliness of the whole series of events, repeating
themselves a thousandfold in every batch of eggs, assures us of a causal sequence conspir-
ing to create an object whose parts are adjusted to make a machine of extraordinary
complexity.
This pageant makes an irresistible appeal to the emotional and artistic sides of our
nature. Hence not without a feeling of jealous regret, the old-fashioned embryologist sees
these gems of nature consigned to test tubes for chemical analyses, to centrifuges to disturb
their arrangements, to microdissecting instruments to pick them to pieces, and to endless
tortures by alterations in the environment to disturb the orderly, normal course of events.
For, it is the automatic self-contained perfection of the developmental process that holds our
interest. Yet we feel, too, that if the mystery that surrounds the study of embryology is ever
to come within our comprehension, we must try not to be sentimental and have recourse to
other means than description of the passing show. The recompense, we hope, will be to
substitute a more intelligent interest in place of the older emotional response to the order of
nature.
(Morgan 1927, p. vii)

Along this line, an important contributor to the biochemical aspects of embryol-

ogy was Noel Joseph Terence Montgomery Needham (1900–1995) (Fig. 7.3a), a
Cambridge University biochemist whose three volume opus of 1931 with more than
4,500 references, Chemical Embryology, synthesized essentially everything known
about this subject. In this work, inspired, in part, by Preyer’s Specielle Physiologie
des Embryo (Preyer 1885), Needham worked chiefly with the avian egg. Here he
attempted to resolve the dispute between “vitalism” and “mechanism” and contribute
to “… the increase of knowledge itself,” presenting “… the physio-chemical history
of embryonic development, from the egg-cell to the losing of the individual into the
activity of post-natal life …” (Needham 1931, p. 38). In this work, Needham pro-
posed a “neo-mechanistic” basis of development with shades of Weltanschuung
[world view or philosophy] (Needham 1931; Schröder 1992).
In his Prolegomena, Needham acknowledged,
If the analogy may be permitted, physico-chemical embryology has so far been living an
intra-uterine existence. Its facts have been buried in a wide range of scientific journals, and
its theories have lain dormant or in potential in reviews of modest scope. Physico-chemical
embryology has, indeed, arrived at the stage immediately prior to birth, and all it needs is a
7.4 Embryology Becomes a Science 127

Fig. 7.3 (a) Joseph Needham (1900–1995). (b) Edward Frederick Adolph (1895–1986)

skilful obstetrician, for, when once it has reached the light of day and has passed for ever
out of the foetal stage, it will be well able to take care of itself.
(Needham 1931, p. 1)

This previously ignored aspect of embryology was fortunate to have as its

accoucheur one with Needham’s background and breadth of knowledge. He pro-
moted the concept of “neo-mechanism as a theory of chemical embryology,” which
regards “the mechanistic view of the world as a legitimate methodological distor-
tion, capable of application to any phenomenon whatever, and possessing no value
at all as a metaphysical doctrine” (pp. 32–35). In his chapter “The theory of chemi-
cal embryology,” Needham reviewed the understanding of embryonic development,
from the Aristotelian view of the principles of causation: “Efficient, Material, Final,
and Formal” Causes (pp. 10–11), which formed the conceptual framework for
almost two millennia, to neo-vitalistic theories of “hormism” or “psychobiology,” to
“finalism” or “dynamic teleology,” to “organicism,” to “emergence” (pp. 14–32).
Needham emphasized that, in contrast to these rather numinous and mystical con-
cepts of metaphysical materialism, “Biology cannot be [both] philosophical and
scientific, emergent and resultant, indeterminate and determinate, teleological and
mechanical at one and the same time” (p. 30). He continued, that “… the most pow-
erful solvent of vitalism …” would be contemporary concepts in physics of uncer-
tainty and indeterminacy, and the rigor of biochemistry and biophysics (pp. 31–32).
Thus, Needham helped to establish embryology beyond a transcendental a priori
basis, rejecting the entelechy of vitalism and mechanism, to that of “… a branch of
exact biology” (Wells 1932, p. 415). Needham concluded, “The physico-chemical
embryologist is not committed to any opinion …. [but] that the scientific method is
one way of describing it and that it is best to apply that method in its full rigour …”
(Needham 1931, p. 14). Needham’s approach echoed that of the philosopher Robin
George Collingwood (1889–1943) that “… mathematics, mechanics, and
128 7 Embryology and Early Developmental Physiology

materialism are the three marks of all science …” (Needham 1931, p. 36). In his
1932 essay, “Thoughts on the problem of biological organization,” Needham
observed, “Whatever the nature of these relations may be they form the central
enigma of biology, and biology will only be fruitful in the future if this is recog-
nized. … The hierarchy of relationships, from the molecular structures of the carbon
compounds … to the equilibrium between species in ecological wholes … will
probably be the guiding idea of the future. But one conclusion is clear … organiza-
tion is a problem to be solved …” (Needham 1932, p. 92). In an extension of the
historical presentation in Chemical Embryology, Needham also published his
exhaustive survey of embryology from antiquity through the end of the eighteenth
century, A history of embryology (Needham 1934). In later years, Needham became
an expositor and scholar of Chinese Science and Civilization (Needham
1954–2004).
Another contemporary scientist who enlarged the horizons of embryology was
Paul Alfred Weiss (1898–1989), originally from Vienna and its Biological Research
Institute, who emigrated to the USA to work with Ross Granville Harrison at Yale,
and later worked at both the University of Chicago and the Rockefeller University.
In his Principles of development…, Weiss stressed that the field was analogous to a
land in its age of discovery, in,
… a state of flux with rapid and unpredictable advances and fascinating prospects … it
combines a review of past achievements with a preview of presumable future trends …. The
growth of our science … [is] as the growth of an organism whose food is the ever increasing
mass of factual knowledge.
(Weiss 1939, p. iii)

In concert with his detailed review of contemporary embryological concepts,

Weiss addressed problematic issues such as development of the nervous system and
the integration of behavior (see below).
In further studies of development, one who worked to discover mechanisms by
which the structure of an organism develops from germinal material, was the zoolo-
gist Charles Manning Child (1869–1954) of the University of Chicago. Another
“graduate” of the Naples Stazione Zoologica, Child in his studies of regeneration
established that these metabolic gradients of growth, whether arranged along a polar
axis (axial gradient), or spreading outward from a central core, were present not
only in the organism as a whole, but in the various individual tissues and cells.
Further, the gradient was demonstrated in terms of functional components such as
oxygen consumption, metabolic rate, enzyme activity, and others. Child’s contribu-
tions were a frontal attack on the central problem of biology, that is how the devel-
oping organism, structurally composed of various cells, achieves pattern, order,
form, unity, and correlation of activities. In an 800+ page 1941 monograph and
summary of his lifework, Patterns and Problems of Development, Child explored
various aspects of the problems of the origin and nature of developmental patterns,
and their physiologic implications (Child 1941; see Blackstone 2006). The “gradi-
ent” theory took its name from his demonstration in planaria that development
occurs in graded physiological stages along the axis with relation to adjacent tissues
(Hyman 1957). Quite obviously, Child’s attempts to solve the mystery of the
7.4 Embryology Becomes a Science 129

regulation of cellular and tissue development, one that continues to the present day,
were premature before the creation of contemporary cellular and molecular biology.
Although beyond the limits of consideration of this review, the concept of “morpho-
gen gradients” is important in today’s developmental biology. This is because it
describes a mechanism by which a signal from one cell group in an embryo can act
upon, and determine, the development/differentiation/lysis, and thus fate, of sur-
rounding cells. As can be imagined, a number of seminal advances have contributed
to an understanding of development (For instance, Cooke 1988; others).
Although strictly speaking, not an embryologist, another who contributed greatly
to thought in this domain was the physiologist Edward Frederick Adolph (1895–
1986) (Fig. 7.3b) of the University of Rochester. Principally an environmental phys-
iologist, Adolph appreciated the vital importance of understanding the emergence
of biologic regulatory mechanisms. In the Preface to his arbeit, Physiological
Regulations, Adolph speculated on what may be a credo for physiologists,
Physiology seems to me more than a science of individual working parts. … Physiological
regulations are patterns of processes; the outcome of all those operating characteristics that
assure the constancy of a property … There is no limit to the patterns of physiological
investigation, for every concept adds a pattern of search. Physiology is more than a technol-
ogy, more than information. It develops new aspects at every turn; as long as it lives it will
include the unorthodox. … Let not wisdom scoff at strange notions or isolated facts. Let
them be explored. For the strange notion is a new vision, and the isolated fact a new clay,
possible foundations for tomorrow’s science.
(Adolph 1943, pp. v–vi)

In his studies, Adolph sought to identify critical aspects of the ontogeny of the
several regulatory systems, in particular those of water balance and renal function,
temperature control, oxygen consumption and metabolism, and the blood and circu-
latory systems. As he noted in his analysis of quantitative relationships, the “…
selected relations among data are manifestations of the processes commonly meant
by the term physiological regulations. They provide a quantitative means of visual-
izing what organisms do to maintain constancy not only of composition, but of
energies, forces, structures, and functioning” (Adolph 1943, p. x). In his studies,
many of which used the developing rat as a model, he categorized regulatory sys-
tems into five major types, and traced the manner in which their development fol-
lowed similar lines or differed. Among his conclusions was the manner in which
these physiologic systems develop during the antenatal period of fetal maturation,
as opposed to suddenly appearing at birth (Adolph 1957).
In his 1968 monograph, Origins of physiological regulations, Adolph expanded
upon the developmental origins of regulatory mechanisms of cardiac function, met-
abolic and endocrinologic pathways, renal function, with comparisons among spe-
cies, and with analysis of the general principles of ontogenesis (Adolph 1968a).
Subsequently, Adolph explored the basis upon which to compare physiologic
developments or “stagemarks” in the fetuses and infants of 16 different species (12
of which he illustrated). Although the ontological sequences of specific functions
and landmarks, which appear step-by-step, were quite similar among the species,
significant differences were observed (Adolph 1970, 1972). A philosopher of
130 7 Embryology and Early Developmental Physiology

science, Adolph emphasized the role of research in self-education and personal

enrichment, in addition to that of its many contributions to society (Adolph 1968b).
A recipient of many honors, Adolph was awarded the US Presidential Certificate of
Merit (1948). Several reviews detail aspects of experimental embryology during the
latter part of the twentieth century (Alexandre 2001; Mulnard 1986).
In a continuation of the studies initiated by Spemann, Needham, Weiss, Child
and others, with contemporary methodologies of cellular and molecular biology,
investigators such as the 2012 Nobel Laureate Sir John Bertrand Gurdon, formerly
of Oxford, and currently with the Wellcome Trust Institute of Cancer Research and
Developmental Biology, Cambridge University, are pursuing the fundamental
mechanisms by which cells originate, transmit, and respond to such signals (Gurdon
1962; Gurdon and Bourillot 2001; Gurdon et al. 1999). Considering the mystery of
morphogen gradients Sir John Gurdon has written,
The question of how a cell can individually recognize and interpret a defined concentration
of a factor in the medium remains, to me, one of the most fascinating problems in cell and
developmental biology. It seems that a single cell can recognize and interpret as little as a
three-fold concentration of a morphogen in its medium. The actual concentration at which
morphogens are recognized is in the picomolar range. I believe this to be well beyond the
sensitivity of human chemo-reception.
(Letter from Sir JBG to LDL, 11 January 2010)

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Chapter 8
Some Aspects of the Physiology of the Placenta

8.1  Late-Nineteenth and Early-Twentieth Centuries

One cannot properly consider the physiology of the fetus without that of the placenta,
a fetomaternal organ characteristic of mammalian pregnancy, upon which the fetus
is dependent not only for the transfer of oxygen and a variety of nutrients, but the
elaboration of a number of hormones and growth factors in the “maternal-placental-­
fetal” unit. Thus, it is perhaps appropriate to review some of the concepts regarding
development of that organ and its function, the intervillous space, villous structure,
and placental classification. The placenta differs from other organs in being formed
by the interaction of both fetal and maternal tissues, shows extreme diversity in its
structure among the species, and is of limited lifespan. Development of the placenta
must be correlated closely with that of the fetus. Near or at term in humans the pla-
centa weights ~0.5 kg, and throughout pregnancy, by mechanisms poorly under-
stood placental mass, maternal and fetal blood flows, villous surface area for nutrient
exchange, and the elaboration of hormones must be matched closely to fetal growth
and development. A history of placental biology might be considered from a number
of perspectives. These include: embryology, variation by species, morphologic
form, microscopic cellular organization, maternal and fetal circulations, the inter-
face between maternal and fetal exchange surfaces, respiratory gas and nutrient
exchange, metabolic, endocrine, and immunologic functions and others. Quite obvi-
ously, considerations of these subjects in detail would require a multivolume treatise
far beyond a simple historical discussion.
Since earliest times, the placenta has been recognized as being of vital impor-
tance, and at the same time quite mysterious—even somewhat mystical. For exam-
ple, in many cultures the placenta has been held as an alter ego [my second self], a
symbol for the preservation of health and good fortune, and as a talisman in case of
danger. In some societies, a sympathetic animism exists between the placenta and
the future adult (Ploss et al. 1935). In early Egypt, the placenta was believed to be
the seat of the “External Soul.” A sculpture on an Egyptian ceremonial slate from

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 137
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_8, © American Physiological Society 2013
138 8  Some Aspects of the Physiology of the Placenta

Hierakonpolis depicts a Pharaoh, in what appears to be a ceremonial procession,

preceded by five attendants, one of whom is bearing a standard interpreted as repre-
senting the Royal placenta with umbilical cord—the Pharaoh’s “soul” or “secret
helper” (Seligmann and Murray 1911). The success and prosperity of the kingdom
was held to be dependent upon the well-being of the sovereign, and the preservation
of his soul or “Bundle of Life” (Murray 1930). The Hebrew scriptures include sev-
eral references to the placenta, sometimes as the “Bundle of Life” and “External
Soul” (For instance, see Deuteronomy 28:57 and I Samuel 25:29) (Long 1963;
Stirrat 1998). In the folklore of many people of the Pacific Islands, Australasia and
Africa, the placenta is variously regarded as a sibling of the infant, a ­companion, or
soul, or otherwise possessing supernatural properties (Longo 1964).
The Greeks recognized the importance of the placenta [flat cake] in fetal nutri-
tion, and named the outermost embryonic membranes chorion [membrane] and the
innermost membrane encompassing the fetus amnion [bowl]. The Greek philoso-
pher–biologist Aristotle (384–322 BCE) may have been the first to use the term
chorion, and he also recognized the yolk sac of lower vertebrates (see Aristotle
1831–1870). Because Aristotle based many of his ideas on findings in ruminants
and other animals, considerable confusion about many topics was perpetuated.
Nonetheless, he did much to establish the science of the study of fetal membranes.
In his great embryological treatise De generatione animalium [On the generation of
animals] (ca. 340 BCE), Aristotle stated that “The [umbilical] vessels join on the
uterus like the roots of plants and through them the embryo receives its nourish-
ment” (Aristotle 1831–1870). The Greek physician–anatomist Galen considered
embryological development, in his treatises De formatu foetus in utero [intrauterine
development of the fetus], De uteri dissectione [dissection of the uterus], and De
usu partium [on births] (Galenus [C] 1914). In these works, Galen maintained that
the uterine vessels open their mouths and unite with the fetal vessels in the chorionic
membranes, thus establishing direct communication between the mother and the
fetus. This was concordant with his view that the left ventricle and arteries supplied
“vital spirits” or “spiritual blood” to maintain the innate heat of the tissues, whereas
the veins supplied the “alimentary blood” to provide pabulum or foodstuffs. His
views on this subject were held as dogma until the discovery of the circulation of the
blood in the early seventeenth century (Galenus [C] 1914). Galen described four
stages of embryonic development: the seminal state, in which the embryo was a
coagulum of semen and menstrual blood; the formation of the tria principia [triad
of principal organs], the brain, heart, and liver; a third stage in which other struc-
tures developed; and finally further growth and maturation of the embryo/fetus
(Needham 1934). In the goat, Galen also described fetal movements, including
those that followed compression or ligation of the umbilical cord (Duckworth
1962). As noted earlier, during the renaissance with its quest for increased under-
standing of many aspects of life, the anatomist Realdo Colombo coined the term
“placenta,” and described many of its features, including noting the importance of
the umbilical vessels. He wrote,
At first, Nature spawns the allantois and those multiple veins and arteries that leave through
the navel. Then, it makes those vessels fuse to each other, to be sustained. Finally, these
vessels divide at the end of their course and form a sort of flat circular cake (that is placenta)…
8.1 Late-Nineteenth and Early-Twentieth Centuries 139

Although placed over the allantois, the placenta does not completely surround the fetus and
strongly adheres to the uterus. It is therefore not surprising that abundant bleeding occurs
during delivery, due to the tearing off of both placental veins and arteries… In humans the
allantois is a large membrane, which completely encloses the fetus… In addition to the two
already mentioned membranes, a third one (the amnion) has to be considered. The amnion
is an envelope in direct contact with the fetus and contains its sweat and its excrement. The
fetus swims in it and is sustained by this fluid, to be less troublesome for the mother.
Don’t marvel that no excrements other than urine and sweat are produced. This is due to
the cleanness and purity of the blood that feeds the fetus. Thus, it is false what common
people believe (i.e. that only menstrual or impure blood reaches the fetus)… When the time
of delivery comes, these two membranes tear off and come out with the fetus. Obstetricians
call “waters” the excremements that flow after the membranes rupture and their coming is
considered a sign of imminent birth. Moreover, if the baby is visible when the waters flow,
the outcome if considered favourable and easier. This is due to the humidity of excremental
liquid that lubricates the mother’s genital channel… The fetus is nourished through the
umbilical cord by its vein. With respect to this… it is fed through the umbilical vein with
good and perfect blood.
(Colombo 1559; see Pizzi et al. 2012)

From the early sixteenth through the eighteenth centuries, if there was a sin-
gle dispute that captured the core of placental developmental biology, it was over
the degree to which the maternal and fetal placental blood vessels were
interconnected.
At mid-nineteenth century, a major point of contention regarded the existence of
the intervillous space and its circulation in maternal–fetal exchange. For instance,
William Benjamin Carpenter (1813–1885) had described an enclosed space, in
which fetal “vascular tufts” were within a cavity, the walls of which were an exten-
sion of the membrane lining the maternal veins and sinuses, and that fetal vessels
were covered by a layer of cells of maternal origin (Carpenter 1854, pp. 626–627).
In contrast, Arthur Farre (1811–1887) wrote, “…the maternal vessels all terminate
at once and abruptly upon the inner surface of the decidua. The curling arteries,
after passing from the muscular coat of the uterus… through the layer of decidua
which forms the roof of the placenta, open directly into the interior of the latter;
while the veins commence by equally abrupt openings which conduct through the
decidual layer to the venous sinuses in the uterine walls” (Farre 1859, p. 719).
Other investigators wrote of maternal blood filling this space (Bumm 1890;
Leopold 1877; Turner 1872, 1876a; Wagner 1851–1859; Waldeyer 1887, 1890).
Despite these demonstrations, however, many could not accept the concept of
maternal blood flowing through an open cavity in the absence of discrete surround-
ing walls. Although many workers accepted the presence of maternal blood in this
space, a common view was that, rather than being in direct contact, a layer of
maternal endothelial membrane separated that blood from the fetal villi (see Boyd
and Hamilton 1970; Corner 1963; Pijnenborg and Vercruysse 2008). As may be
appreciated, firm evidence of this circulation of maternal blood through the inter-
villous space awaited both more advanced microscopy and the cineradiographic
studies a century later.
It should be noted that even at this time physiologic functions of the placenta
were poorly understood (De Witt 1959). For instance, in a series of lectures at the
140 8  Some Aspects of the Physiology of the Placenta

Fig. 8.1 (a) Sir William Turner (1832–1916). (b) Theodor Langhans (1839–1915). (c) George
Washington Corner (1889–1981). (d) Louis Flexner (1902–1996)

Royal College of Surgeons, Edinburgh, William Turner (later Sir William; 1832–
1916) (Fig. 8.1a) of the University of Edinburgh summarized contemporary knowl-
edge of placental structure, and likened the fetus to a parasite:
The foetal placenta possesses an absorbing surface; the maternal placenta a secreting sur-
face. The foetus is a parasite, which is nourished by the juices of the mother… As there are,
therefore, two sets of secreting structures in the gravid maternal mucosa, the Glands and the
Crypts… it may be a matter of consideration how far the secreting organs perform similar
or different functions in foetal nutrition… The current doctrine that the nutrition of the
foetus is provided for by the simple percolation or diffusion of materials through the walls
of the vessels from the maternal blood to the foetal blood can no longer be accepted.
(Turner 1876a, p. 114ff)
8.1 Late-Nineteenth and Early-Twentieth Centuries 141

A Lancet reviewer of Turner’s treatise wrote, “All Professor Turner’s work is so

honest and good that it is unnecessary we should do more than direct our reader’s
attention to the publication of these lectures to induce them to procure a copy for
themselves” (Anonymous 1876, p. 541). Despite this somewhat confusing view of
placental function, Turner made a number of important contributions to an under-
standing of placental structure, particularly in regard to its comparative anatomy
with striking interspecies differences (Turner 1876a). He also was a founding editor
of the Journal of Anatomy and Physiology (1866) (Haig 1997; Magee 2003; Turner
1872, 1876b, 1919).
Another issue of disagreement at this time was the nature of the outermost cells
of the placental villi in the human. Theodor Langhans (1839–1915) (Fig. 8.1b),
when serving as Professor of Pathology at the University of Berne, correctly identi-
fied the villous covering of chorion frondosum [chorion villosum] and chorion
laeve [chorion avillosum] as being of fetal origin, and as forming a continuous layer
from the early stages of development (Langhans 1870). Several years later,
Langhans demonstrated that this membrane comprised two layers, the outer-
most Chorionepithel [chorionic epithelium] of continuous cells, and underlying
Zellschicht [cell layer] of large, individual, epithelial cells, with cellular boundaries/
membranes. We now know these as the syncytiotrophoblast [cells together + tropho-
blast] and cytotrophoblast [cellular + trophoblast], or “Langhans” layer, respectively
(Bonnet 1903; Boyd and Hamilton 1966; Langhans 1877, 1882). In regard to the
syncytiotrophoblast and cytotrophoblast, Langhans noted that the epithelium
covering the outer surface of the chorion and villi forms a uniform layer of rather
homogenous cytoplasm containing nuclei, but without a clear division into indi-
vidual cells. Particularly in younger ova, he observed lines that might represent
boundaries of cells of highly variable form, with large, often multiple finely granular
protoplasm, and nuclei, the diameter of which were several times that of those in
the overlying chorionic epithelium (Langhans 1877).
A related contribution was that of Ambrosius Arnold Willem Hubrecht (1853–
1915), Professor of Zoology at the University of Utrecht, who, in contributing to an
understanding of the process of implantation, introduced the term trophoblast
[nutrition + germ] to indicate that portion of the blastocyst not contributing to for-
mation of the embryo per se, but rather forming the placental villi for the nourish-
ment of the embryo (Hubrecht 1888, 1889). Although working with several species,
for these studies Hubrecht selected the placenta of Erinaceus europaeus (the hedge-
hog) (Hubrecht 1889; Pijnenborg and Vercruysse 2013). Hubrecht appreciated the
double cellular layer, with the outer layer of nuclei in “nests” not demonstrating
mitosis, and the innermost layer of cylindrical cells. According to his original
description, trophoblast had limited morphologic significance; however, before long
it came to apply to the epithelial derivatives of the outer layer of the blastocyst, the
two cell layers described by Langhans. Hubrecht’s collection of mammalian
embryos and placentas, maintained for many years at the Hubrecht Laboratory in
Utrecht (Faasse et al. 1999), currently is at the Museum für Naturkunde der
Humboldt-Universität, Berlin (Carter 2008).
142 8  Some Aspects of the Physiology of the Placenta

Further technical and conceptual contributions to understanding placental

morphology were those of Charles Sedgwick Minot. Minot suggested the term
trophoderm to describe the mature placental cells; however, this never became
widely accepted. Nonetheless, he presented a definitive account of the microscopic
structure of the human placenta, in one instance describing a section through the
uterus and placenta in situ at 7 months gestation, with amnion, chorion, villus trunk,
sections of villi in the substance of the placenta, decidua, muscularis, uterine blood-­
vessels opening into the placenta, and so forth (Minot 1889, 1891). In a later review,
Minot noted that the chorion is separated by a dense forest of villi from the decidua,
that the termini of some of the villi touch and are imbedded in the decidual tissue,
and that the decidua is divided into two strata. He described the section passing
through a wide tube, a vein containing blood, that opened into the interior of the
placenta (Minot 1903). These contributions did much to help clarify the nature of
the maternal–fetal barrier of the placenta. His overview of embryologic-placental
development Human Embryology (Minot 1892, 1897) was a “classic.” A distin-
guished scientist and member of the National Academy of Sciences, Minot served
as President of the American Society of Naturalists (1894–1895), American
Association for the Advancement of Science (1901), and the American Association
of Anatomists (1904–1905) (Lewis 1914; Morse 1920).
An additional contribution of this era was a system of classification of the mam-
malian placenta. As is widely appreciated, diversity of placental anatomy, both
gross morphologic and microscopic structure, characterizes viviparity. Thomas H.
Huxley, who held that the presence of decidua demonstrated the common descent of
a group of mammals, divided mammals into those non-decidua, adeciduate, inde-
ciduate, in which at parturition there was no loss of maternal tissue, and those
deciduate, in which the decidua underwent lysis (Huxley 1864). Soon, however, it
came to be appreciated that this view was inexact. Another classification was that
of Hans Strahl (1857–1920), of Giessen, who categorized placenta as those
Vollplacenten [complete placentae], in which at birth the maternal blood space is
opened and part of the decidua sloughs off, and Halbplacenten [semi placentae], in
which the cavity of maternal blood remains intact (Strahl 1902, 1908). In turn, the
anatomist–embryologist Arthur Robinson (1862–1948), of Edinburgh and London,
suggested the term “apposed placentae” for those instances in which the chorionic
membrane is closely applied to the uterine decidua, and “conjoined placentae” for
those cases in which the layers are fused (Robinson 1904). Another nomenclature
suggested was that of placentae plicate, with a rather uncomplicated chorionic epi-
thelium, and placentae cumulatae, with a complex trophoblastic structure that
included lacunae for maternal blood (Assheton 1906). Contributing to an under-
standing of the changes in relationship of the uterine decidua and attached fetal
structures throughout the course of gestation was the 1901 volume Human placen-
tation… by John Clarence Webster (1862–1950) (Webster 1901). Including draw-
ings and over 200 microphotographs, it detailed the gestational decidua with
invasion of trophoblast cells of placental villi.
Among the various species, a characteristic feature of the placenta is the number
of tissue layers that separate the maternal and fetal blood streams. Of physiologic
8.2  Mid-Twentieth Century to the Present: Placental Fine Structure and Function 143

interest is the extent to which these different tissues determine the placenta’s
function. For this purpose, the classification of placental types most well known to
contemporary students of the subject is that of Otto Grosser (1873–1951), Professor
of Anatomy at the University of Prague. Grosser defined the various chorioallantoic
placental types on the basis of the number of tissue layers and cell types that, late in
gestation, are interposed between the maternal and fetal blood streams, e.g.,
epithelio-­chorial, syndesmo-chorial, endothelio-chorial, hemo-chorial, and hemo-­
endothelial (Grosser 1908, 1909, 1910, 1927). Regarding Grosser and his contribu-
tions, the embryologist George Washington Corner (1889–1981) (Fig. 8.1c) stated,
“… more than any other investigator, [he] has taught us to see in all that [placental]
complexity a basically similar pattern in the relation of the maternal to fetal blood-
streams, throughout the mammalian order” (Corner 1963, p. 417). Nonetheless,
several considerations have pointed to conceptual problems with Grosser’s classifi-
cation. These include the complexity of the placental barrier in terms of differing
mechanisms of exchange, the lack of consideration of the yolk sac, and several
aspects of placentation early in development with changes during the course of
gestation (Enders 1965a, b; Wislocki 1955). Importantly, contemporary studies
using the electron microscope have contributed greatly to understanding placen-
tal fine structure and its complexity (Wislocki and Dempsey 1955; Wislocki and
Padykula 1961). As Emmanuel Ciprian Amoroso (1901–1982) (Amoroso 1959a, b;
Lawn et al. 1969), Allen Coffin Enders (Carter and Enders 2004; Enders 1965a, b),
and others (Björkman 1968), have emphasized, use of the Grosser classification
critically depends upon an understanding of its limitations. For instance, electron
microscopic studies have disclosed at least four subdivisions of Grosser’s hemo-
chorial placental type, e.g., hemo-trichorial, hemo-dichorial, labyrinthine hemo-­
monochorial, and villous hemo-monochorial (Amoroso 1955; Enders 1965a, b).

8.2  M
 id-Twentieth Century to the Present: Placental Fine
Structure and Function

At mid-century, several issues were paramount in terms of understanding placental

morphology and function. An important contributor to an understanding of placen-
tal morphology was Harland Winfield Mossman (1898–1991) of the Department of
Embryology of the Carnegie Institute of Washington, located in Baltimore. In his
1937 monograph on mammalian fetal membranes, Mossman surveyed the placenta
and its membranes from both a developmental and comparative standpoints
(Mossman 1937). Fifty years later, he expanded this treatise into his Vertebrate fetal
membranes… (Mossman 1987). From the standpoint of physiology of the placenta
and fetal membranes, this work is important for its presentation of morphologic cor-
relates for biological function. Mossman has described some aspects of these con-
tributions and their impact (Mossman 1991; see also Steven 1975).
In Great Britain, Amoroso also contributed to knowledge of this subject of early
placental development in a number of species (Amoroso 1952, 1955, 1959b), as did
144 8  Some Aspects of the Physiology of the Placenta

Fig. 8.2 (a) James Dixon Boyd (1906–1968). (b) William James Hamilton (1903–1975).
(c) Elizabeth Ramsey (1906–1993). (d) Kurt Benirschke with a porcupine

Gordon Bourne (Bourne 1962) and James Dixon Boyd (Fig. 8.2a) with William
James Hamilton (1903–1975) (Fig. 8.2b) in the human (Boyd and Hamilton 1970).
For instance, by examining these tissues in situ attached to the decidua and uterine
wall in humans, Boyd and Hamilton traced development of the placenta from the
time of implantation to the end of pregnancy. They demonstrated the lack of
evidence for Rudolf Spanner’s concept of maternal blood flow through the intervil-
lous space, presented evidence for the morphologic changes in the uterine spiral
arteries as they course through the decidua, with their invasion of trophoblastic
cells, the development of stromal trophoblastic buds and giant cells, and specialized
aspects of chorionic syncytium, and the development of interlobular septa. These
8.3 The Uteroplacental Circulation, Transplacental Exchange, and an Introduction… 145

workers also commenced a statistical analysis of placental and fetal growth (also
see Boyd and Boyd 2010). In his Campbell oration to the Ulster Medical Society,
Boyd predicted that,
… surely, the placenta will deserve… increasing attention, for it is the essential structural
basis of the prenatal relationship between mother and child. …Derived by differentiation
from cells that possess the potentiality of living for seventy, or more, years, its constituents
sacrifice themselves after ten lunar months. Built up of disparate cytological elements
derived from two heterozygous individuals, it has functions so diverse as to overlap those
carried out, in the adult, by lungs, liver, intestinal tract, kidneys, and endocrine glands. …
For any satisfying explanation of the relation of the unborn child to its mother the darkness
of the intra-uterine workmanship must first be made visible and the inscrutability replaced
by biological answers to rational questions.
(Boyd 1959, p. 45)

Other scientists at the Carnegie Institution of Washington who contributed to our

current understanding in this area include George Linius Streeter (1873–1948),
George W. Corner, and those who utilized carefully timed pregnancy in the Rhesus
monkey (Macaca mulatta), as well as human tissue, to advance the knowledge of
early embryonic development (Corner 1963; Corner et al. 1963; Hartman 1932;
Streeter 1920, 1926, 1942, 1945, 1948, 1949; Streeter et al. 1951). At the Harvard
Medical School, additional vital contributions to implantation and early embryonic
development in humans were made by the anatomist George Bernays Wislocki
(1892–1956), the pathologist Arthur Tremain Hertig (1904–1990), and obstetrician
gynecologist John Rock (1890–1984) (Hertig 1935, 1945, 1962; Hertig and Rock
1941, 1942, 1943, 1944a, b; Rock and Hertig 1942, 1943; Wislocki 1955, 1956;
Wislocki and Dempsey 1955; Wislocki and Padykula 1961). A number of other
individuals have contributed monographs or other writings on placental morphology
and its structure (Björkman 1970; Brosens 1965; Gruenwald 1975; Kaufmann and
King 1982; Moawad and Lindheimer 1982; Moghissi and Hafez 1974; Strauss et al.
1967; Torpin 1969; Wilkin 1965).

8.3  T
 he Uteroplacental Circulation, Transplacental
Exchange, and an Introduction to Placental
Endocrinology

The miracle of embryonic and fetal development requires the formation of a cardio-
vascular system in the embryo and fetus, and a complex vasculature within both the
maternal and fetal side of the placenta (Thornburg and Louey 2013). The physiolog-
ical principles that regulate these flows are similar to those of other organs, e.g.,
driving pressure and vascular resistance. As with other vascular beds, these may, in
part, be regulated by a host of vasoactive chemicals and hormones.
In mammals, the adaptations to pregnancy require sizeable alterations in struc-
ture and function of the circulatory system, particularly that of the uterine circula-
tion (Hytten and Leitch 1964; Osol and Mandala 2009; Reynolds et al. 2006, 2013).
During the course of human gestation, although maternal red cell mass increases
146 8  Some Aspects of the Physiology of the Placenta

~30 %, that increase of plasma volume is ~50 %, resulting in an ~40 % increase in

blood volume (Longo 1983). In addition to the uterus, remodeling of the human
cardiovascular system is accompanied by increases in blood flow to the breast and
kidney, such that cardiac output increases ~20–30 % by 30 weeks gestation, and
then declines somewhat to term (Hytten and Leitch 1964; Longo 1983). The several
mammalian species accomplish these changes by different mechanisms, both ste-
roid and protein hormones playing a major role in these changes (Chang and Zhang
2008). Estradiol 17β probably is the most potent steroid in this regulation (Longo
1983; Siiteri and MacDonald 1966), in great part by its stimulation of eNOS with
NO production (Rupnow et al. 2001). As would be expected, a number of other
hormones and factors play key roles in remodeling of the uterine vasculature (Chang
and Zhang 2008; Osol and Mandala 2009).
As background for an understanding of placental exchange, in his late eighteenth
century magnum opus, the two volume Zoonomia on natural science, bodily func-
tions, and medicine, the British physician, botanist, and poet Erasmus Darwin
(1731–1802) devoted a chapter to the placenta (Darwin 1794–1796). Grandfather of
both Charles Darwin (1809–1882) and Sir Francis Galton (1822–1911), Darwin
appreciated the significance of oxygen, which had been discovered two decades
earlier, in respiration of the lungs and fish gills. Observing the change in color from
dark to light red as fetal blood passes through the placenta, Darwin postulated that
the organ serves as the major organ of oxygenation for the fetus. Erroneously, he
believed the fetus’ main source of nutrition was the amniotic fluid (Pijnenborg and
Vercruysse 2007). It would remain many years before Darwin’s enlightened views
on placental respiration were more fully valued.
As noted above, the umbilical and placental circulation constitutes a shunt in the
fetal circulatory system. Derived from the allantois in the early embryo, this is
critical for delivery of O2 and nutrients to the developing organism. As is evident,
placental growth, development, and blood flow must keep place with that of the
fetus, although the mechanisms by which this synchrony is orchestrated are poorly
understood. A rather complex subject in itself, development of this vascular bed has
been summarized by others (Anderson and Faber 1984; Burton et al. 2009, 2011;
Demir et al. 2006). Critical to development of the placenta and its vascular tree is
oxygen, hypoxia during its early genesis being associated with increase in a number
of growth factors including vascular endothelial growth factor (VEGF), placental
growth factor, and others (Ahmed et al. 2000). Rather than being unresponsive,
many substances are known to affect placental and umbilical vessels, and these have
been tabulated (Thornburg and Louey 2013). Because of its relevance to complica-
tions of pregnancy in the human, a number of “models” of compromised placental
blood flow have been described (Gagnon et al. 1994; Giles et al. 1985, 1989; Owens
et al. 1986; Robinson et al. 1979; Trudinger et al. 1987). A challenge for the obste-
trician–gynecologist–perinatologist, and about which we know little, is to recognize
impaired utero- and umbilical perfusion in its early stages. Additionally of impor-
tance is the development of therapeutic interventions to correct this pathology.
The major determinant of intrauterine growth is the placental supply of nutrients
to the fetus, which occurs primarily by diffusion and transporter-mediated exchange.
8.3 The Uteroplacental Circulation, Transplacental Exchange, and an Introduction… 147

These functions depend, in turn, upon the size, morphology, blood supply, and
exchange capacity of the placenta, as well as the synthesis and metabolism of nutri-
ents and hormones by the placenta itself. For the physiologist who investigates func-
tion at a systems level, the placenta presents distinct problems and is unique in many
respects. Essentially every known substance (except perhaps macromolecules)
exchange across the placenta by passive diffusion, facilitated diffusion, active trans-
port, endocytosis, or other mechanisms. In addition, because of its numerous endo-
crinologic and immunologic functions, for the developing fetus the placenta serves
as a lung, liver, kidney, and so forth. One of the challenges in placental function is
that of understanding the mechanisms by which its nutrient exchange is matched to
the requirements of fetal growth (Longo 1987). The placenta also presents chal-
lenges in terms of the Heisenberg uncertainty principle (named for Werner Heisenberg
(1901–1976)), in that the act of quantifying a given function alters the value of the
parameter being measured. An example concerns the transfer of specific compounds,
ions, carbohydrates, proteins, and so forth from the blood of the mother to that of
the fetus (see Dancis 1959; Longo 1972; Meschia 2009; Snoeck 1958; Villee 1960).
A pioneer in these studies was Louis Flexner (Fig. 8.1d) of Johns Hopkins
University and the Department of Terrestrial Magnetism, the Carnegie Institution of
Washington. With his interest in chemical embryology, stimulated in part by his
having spent 9 months working with Barcroft in 1933–1934, with his colleagues,
Flexner first used radioactive isotopes to study placental transfer, and, in fact, pre-
sented one of the earliest reports of the use of radioisotopes for any biological stud-
ies (Flexner and Roberts 1939). In his Reminisces of early studies of placental
function, Flexner has recounted the manner in which he first used radioisotopes for
these studies.
First of all, I must mention the close relationship that existed at the time between the Department
of Anatomy of the School of Medicine, Johns Hopkins University, and the Department of
Embryology, Carnegie Institution of Washington. Lewis Hill Weed [1886–1952] was the
Director of the Department of Anatomy and additionally was a trustee of the Carnegie
Institution. The Department of Embryology, headed by George Linius Streeter [1873–1948],
occupied space in a building of the medical school close to the Anatomy Department.
My appointment was in Anatomy; my interest at the time was in chemical embryology.
I was one of several staff members who felt at home in both departments.
Each spring, Dr. Streeter arranged a day’s program of work in progress in embryology
which was attended by Dr. Vannevar Bush [1890–1974], the President of the Carnegie
Institution. At the annual meeting in 1937 or 1938, I was invited to talk about work I was
doing on the fetal kidney. When the session was over, Dr. Bush came up to me and asked if
I’d ever thought of using radioactive isotopes. I remember having answered his question
with another, “What’s a radioactive isotope?” He quickly made this clear to me, then pro-
ceeded to tell me why he had approached me.
The group in nuclear physics at the Carnegie’s Department of Terrestrial Magnetism
had proposed that the Institution build a cyclotron. Dr. Bush warmly favored the proposal
but told me that it was an expensive proposition and that both he and the Trustees of the
Institution would find the request easier to meet if the isotopes produced by the cyclotron
could be put to biological use. I was left with the invitation to think things over and if I came
up with an idea to let him know through Dr. Weed.
(Flexner 1972, pp. 849–850)
148 8  Some Aspects of the Physiology of the Placenta

He continued,
The day after my conversation with Dr. Bush, I was in Dr. Weed’s office; a few days later,
I was in Washington meeting the group in nuclear physics at the Department of Terrestrial
Magnetism, in particular, Merle Tuve, Richard Roberts, and Dean Cowie. These physicists
could not have been more cordial or more supportive of my interests. At the time, they were
dependent upon an electrostatic generator to produce radioisotopes and a string electrome-
ter to measure radioactivity. All limitations considered, they decided that the first effort with
my problem should be made with radioactive sodium and, because I lacked an instrument
to measure radioactivity, that I should bring pregnant animals from Baltimore to Washington.
Shortly afterward, Dr. Roberts and I got down to business, and all went well except for a
single episode. I injected precious isotope into an animal which I judged to be at an early
stage of pregnancy. When I opened the abdomen and searched for the fetuses, none could
be found. And I could not locate a uterus. As has happened often since that time, Dr. Roberts
solved the problem. The experimental subject I had chosen was a male.
(Flexner 1972, p. 850)

In part, to correlate the Grosser classification of placental layers to function

(which proved not to be possible), Flexner and colleagues demonstrated in the rat an
increased transfer of sodium and water per gram of placenta as gestation proceeds.
They also noted a correlation between the quantity exchanged and the morphologic
structure of the placenta (although it is now recognized that factors other than the
number of cell layers are probably more important in limiting placental transfer).
These workers observed an inverse correlation between the quantity of radioactive
sodium exchanged and total fetal mass during the last 4 days of gestation (Flexner
and Gellhorn 1942; Flexner and Roberts 1939; Hellman et al. 1948). They con-
cluded, “There is good reason to believe that in the concentrations used here radio-
active substances behave like their more common isotopes. This, together with the
direct approach which it provides to physiological problems… makes the use of
radioactive isotopes of unique value in the study of many phases of placental perme-
ability. The method, in addition, is the more valuable because of the ease and exact-
ness of quantitative determinations” (Flexner and Roberts 1939, p. 157). Following
the war, Flexner used tritiated water, 3H2O, to extend his studies of placental transfer
to humans (Flexner 1955; Flexner et al. 1948; Hellman et al. 1948). Introduction of
the use of radioisotopes in biological research, led to a revolution in the discovery
of many details and nuances of metabolism and other functions, as well as that of
the hitherto unsuspected activity and dynamic state of body constituents (For
instance see Davison and Dobbing 1961; Schoenheimer 1946). Jan Job Faber, of
Oregon Health Sciences University, has presented a review and critique of Flexner’s
studies of transplacental clearances (Faber 1999). Flexner also explored the bio-
chemistry of development, neurochemistry, the physiology of the cerebrospinal
fluid and meninges, and the basis of memory. Flexner has noted his good fortune to
have been “… in just the right place at the right time” (Flexner 1972, p. 850; see also
Sprague 1998).
Despite increasing understanding of placental fine structure, the issue of uterine
circulation in the intervillous space remained somewhat of an enigma. Following
their continued investigation of early embryonic-placental development (Ramsey
1937, 1938), a group of Carnegie Institution investigators, following the lead of
8.3 The Uteroplacental Circulation, Transplacental Exchange, and an Introduction… 149

Barclay, Franklin, and colleagues several decades earlier, commenced a series of

studies in their primates using cine-angio-radiography to explore this conundrum.
Leaders in this endeavor were Elizabeth Mapelsden Ramsey (1906–1993) (Fig. 8.2c)
and Samuel R.M. Reynolds, and their colleagues. Corner has recounted his partici-
pation in these studies, and in sorting out the mysteries remaining since the time
of John Hunter (1728–1793) and his brother William Hunter with Colin Mackenzie
(ca. 1715–1775) two centuries earlier, of the “… unexplored maze of the human
placenta” (Corner 1963, pp. 417–418). The Carnegie group investigated questions
including uterine blood flow regulation and whether, in the human placenta, the
pattern of maternal and fetal blood flow was that of a “countercurrent” exchange as
had been suggested in studies of the domestic cat (Tafani 1887). This became a
topic of interest in comparative placentology, thanks primarily to the histologic
studies of Mossman, who demonstrated in the labyrinthine placenta of small rodents
and rabbits that maternal and fetal microcirculations appear to run in opposite
direction (Mossman 1926).
The physiological relevance of these observations is important as a “countercur-
rent” exchange pattern is highly efficient, allowing fetal blood exiting the placental
capillaries to exchange respiratory gases with maternal arteriolar blood. As a conse-
quence, the oxygen partial pressure of umbilical venous blood would approach that
of uterine arterial blood. However, as the human placenta is not labyrinthine, uterine
arteries do not carry oxygenated blood all the way to the fetal surface of the organ;
rather, that blood is ejected into the intervillous space from the spiral arterial open-
ings in the basal plate. With this arrangement, nonetheless, it would be possible for
maternal arterial blood ejected under pressure deep into the fetal surface of the
placenta, to be reflected toward the venous openings on the basal plate, creating a
stream of blood that runs in opposite direction to that of the fetal blood flowing
toward the umbilical vein from the tips of the chorionic villi, which in effect is a
countercurrent exchange mechanism (Ramsey 1973).
In visualizing the intervillous flow pattern in the rhesus monkey, the cineradioan-
giographic studies of Ramsey and colleagues demonstrated intermittent function-
ing, with blood being propelled by the vis a tergo toward the chorionic villi as
arteriolar “spurts” into the intervillous space in a somewhat stochastic process
(Martin et al. 1964, 1966; Ramsey et al. 1960, 1963, 1967). She called this a “wink-
ing and blinking” circulation (Longo and Meschia 2000). In contrast to studies in
the rabbit (Faber and Hart 1966) and guinea pig (Moll and Kastendieck 1977), phys-
iological data from the rhesus monkey (Parer and Behrman 1967) and human (Pardi
et al. 1992) have failed to provide evidence of countercurrent placental exchange.
Another model suggested by histologic studies is the so-called multi-villous pattern
of intervillous space perfusion (Bartels and Moll 1964). Here, gas exchange has
intermediate effectiveness between the countercurrent and concurrent systems, and
such a model appears appropriate for the human and other primate placentas.
In concert with these studies, a related consideration was that of understanding
the anatomic/morphologic relations of maternal and fetal blood flow in the placental
exchange area. Among those working on this was Samuel R.M. Reynolds, who had
moved to the University of Chicago. Reynolds integrated his and the findings of
150 8  Some Aspects of the Physiology of the Placenta

Table 8.1  Principal factors affecting placental O2 transfer

Variable Associated components
Placental diffusing capacity Membrane diffusing capacity (area, thickness, solubility,
(Dp) diffusivity of tissue), capillary blood volume, diffusing
capacity of blood (O2 capacity, Hb reaction rates, concentra-
tion of reduced Hb)
Maternal arterial PO2 (PmaO2) Inspired PO2 alveolar ventilation, mixed venous PO2, pulmonary
blood flow, pulmonary diffusing capacity
Fetal arterial PO2 (PfaO2) Maternal arterial PO2, maternal placental Hb flow, placental
diffusing capacity, umbilical venous PO2, fetal O2 consump-
tion, peripheral blood flow
Maternal Hb–O2 affinity pH, temperature, PCO2, 2,3-diphosphogylcerate concentration,
(Pm50) CO concentration
Fetal Hb–O2 affinity (Pf50) pH, temperature, PCO2, 2,3-diphosphogylcerate concentration,
CO concentration
Maternal placental Hb flow Arterial pressure, placental resistance to blood flow, venous

rate ( Qm Hb ) pressure, blood O2 capacity
Fetal placental Hb flow rate Umbilical artery blood pressure, umbilical venous blood pressure
 )
( Qf (or maternal vascular pressure under conditions of sluice
Hb
flow), placental resistance to blood flow, O2 capacity of blood
Spatial relation of maternal
to fetal flow
Amount of CO2 exchange
( VCO2 )
PO2 and PCO2, partial pressures of O2 and CO2, respectively; Hb hemoglobin (adapted from Longo
1987)

others of the cotyledonary “structure,” with maternal blood from the spiral arteries
spurting into the center of an “implanted crown” of anchoring villi, and surrounding
third-order umbilical vessels in free villi forming a tambour (Bøe 1953; Wilkin
1958). Reynolds also correlated knowledge to that time of the day-by-day and
week-by-week morphogenic changes with their functional implications (Reynolds
1966). In an attempt to correlate morphologic features with physiologic functions,
Reynolds, working with Roberto Caldeyro-Barcia (1921–1996) and colleagues
from the University of Montevideo, Uruguay, and using cinefluoroscopy with the
microballoons they had developed to measure uterine myometrial pressures, mea-
sured pressures in the intervillous space of the Rhesus monkey. They concluded that
pressures were highest at the central cavity of the cotyledon, gradually diminishing
towards the subchorial lake, supporting the idea of the central entry of uterine blood
into the cotyledon intervillous space, and flowing toward the periphery (Reynolds
et al. 1968).
Additionally, one must consider the major factors that affect placental O2
exchange. These include: the O2 partial pressures in maternal and fetal arterial
blood, the respective hemoglobin O2 affinities, maternal and fetal placental blood
flows, the anatomical-spatial relations of these blood flows in the exchange area, the
placental diffusing capacity, and others (Longo 1987). These are presented in
Table 8.1. Also of importance is the extent to which the placenta is a substantial
8.3 The Uteroplacental Circulation, Transplacental Exchange, and an Introduction… 151

barrier limiting exchange between the maternal and fetal circulations. This is of
particular relevance to the respiratory gases O2 and CO2 and the extent to which this
possible barrier increases during the course of gestation. As noted earlier, an origi-
nal concept was that near term the fetal arterial tensions fell, so that the newborn’s
first breath was the fetus’ “dying gasp.” A thoughtful placentologist and early mem-
ber of the “Barron School,” André Eugène Désiré Joseph Hellegers (1926–1979) of
Georgetown University, reviewed the development of “… opinions about the pla-
centa as a barrier to oxygen.” Presenting a Jesuitically reasoned analysis of Thesis
and Antithesis, he examined the idea of the fetus being at “Mt. Everest in utero,”
with the placental barrier being a “hazard” to the developing conceptus (Hellegers
1969/1970). In addition to a number of other contributions to placental physiology,
Hellegers also was a leader in the development of bioethics in America (see below).
By measuring PO2 values in uterine and umbilical veins, several investigators calcu-
lated the mean maternal to fetal O2 tension difference to equal 40–50 Torr (Barron
1946; Barron and Alexander 1952; Metcalfe et al. 1967). This suggested that the
placenta was a significant barrier to diffusion, and was associated with the idea that
fetal umbilical PO2 and oxyhemoglobin saturation values fell dramatically as term
approached (Bartels et al. 1962). In near-term pregnant ewes, the Barron group with
Giacomo Meschia also performed the first studies of placental to fetal O2 exchange
at high altitude, on the alto plano of Peru. Of interest, at this altitude fetal blood gas
values (Metcalfe et al. 1962a), blood volume (Prystowsky et al. 1960), and weights
(Metcalfe et al. 1962b), did not differ significantly from those in their near sea level
laboratory in New Haven. As noted, in part, these findings also gave rise to the view
of the fetus being at “Mount Everest in utero” (Eastman 1954), and the “first breath
of the newborn” being the “dying gasp of the fetus.” Subsequent studies using car-
bon monoxide to measure the placental diffusing capacity (a measure of exchange)
indicated that the mean maternal to fetal PO2 difference equals only 5–6 Torr (Longo
et al. 1967, 1969). This would allow virtual equilibration of maternal and fetal O2
tensions within the placental microcirculation, and suggest that the placenta is not a
functional barrier for respiratory gas exchange (Longo 1987; Meschia 2009;
Wilkening and Meschia 1992). Table 8.2 presents the normal blood gas and pH
values in both maternal and fetal arterial and venous blood (Longo 1987).
A related issue of fundamental interest is that of uneven perfusion of the pla-
centa, somewhat similar to that in the lung. Such nonuniform perfusion can result in
unequal oxygenation of fetal blood in portions of the placental microcirculation, so
that the blood returning to the fetus via the umbilical vein results from the mixing
of blood streams with different oxyhemoglobin saturations. Given the shape of the
oxyhemoglobin saturation curve, this mixing would yield an oxygen partial pres-
sure in the collecting vein that is biased toward the lowest PO2 values in the mixture
(Longo and Power 1969; Power and Longo 1969). Ramsey’s visual demonstration
of nonuniform “winking-blinking” placental perfusion has been substantiated by
the use of radioactive microaggregates and of microspheres into the maternal and
fetal sheep circulations to show a nonuniform distribution of both maternal and fetal
placental blood flows and of the maternal/fetal blood flow ratio (Power and Jenkins
152 8  Some Aspects of the Physiology of the Placenta

Table 8.2  Normal values of O2, CO2, and pH in human maternal and fetal blood
Maternal uterine Fetal umbilical
Artery Vein Vein Artery
PO2, Torr 95 38 30 22
HbO2, % saturation 98 72 75 50
O2 content, ml·dl−1 16.4 11.8 16.2 10.9
O2 content, mM 7.3 5.3 7.2 4.5
Hb, g·dl−1 12.0 12.0 16.0 16.0
O2 capacity, ml·dl−1 16.4 16.4 21.9 21.9
O2 capacity, mM 7.3 7.3 9.8 9.8
PCO2, Torr 32 40 43 48
CO2 content, mM 19.6 21.8 25.2 26.3
HCO−3 18.8 20.7 24.0 25.0
pH 7.42 7.35 7.38 7.34
PO2 and PCO2, partial pressures of O2 and CO2, respectively; Hb hemoglobin (adapted from Longo
1987)

1975; Power et al. 1967, 1972, 1981). The evolution of ideas about respiratory gas
exchange in the placenta has been characterized by a continuous effort to identify
the factors of major importance in oxygenation of the fetus. Without doubt, the criti-
cal factors are uterine-placental and umbilical blood flows, maternal and fetal arte-
rial oxygen levels, and placental diffusion characteristics (Longo 1987). Additional
considerations of placental physiology, structure, blood flows, maternal-to-­fetal
exchange, and perfusion techniques have been reviewed by Job Faber and Kent Lu
Roy Thornburg of the Oregon Health Sciences University (Faber and Thornburg
1983). These authors also have reviewed several of the challenges that face the
experimental investigator of placental function, e.g., species differences in anatomy,
physiology, and other aspects, size limitations for given studies, availability of
experimental animals, and others, so that “… imperfect comparisons between ani-
mals and humans must suffice” (Faber and Thornburg 1983, p. xv). Several sympo-
sia also review these and other issues (Wallenburg et al. 1981; Young et al. 1981).
Yet another area of consideration, and one that could require an entire chapter, is
that of the placental transfer of the sugars, amino acids, and other substrates as well
as compounds such as iron, copper, and zinc (Battaglia and Meschia 1978; Hill and
Young 1973; Yudilevich and Sweiry 1985).
Additional contributions during the past several decades, include understanding
nuances of placental development (Kaufmann and Frank 2004), and the importance
of placental hormone synthesis and metabolism. These, with knowledge of the criti-
cal dependence upon, and interactions among, the fetal adrenal gland and other
organs, the maternal endocrine system and the placenta, have led to the concept of
the functional “maternal-placental-fetal unit” or “complex” (Diczfalusy 1964).
These hormonal relationships are important in terms of fetal growth and
8.3 The Uteroplacental Circulation, Transplacental Exchange, and an Introduction… 153

development (Evseenko et al. 2007; Kingdom et al. 2000), the regulation of mater-
nal blood volume in pregnancy (Longo 1983), the role of the fetal–placental unit as
a factor in the initiation of labor (Beshay et al. 2007; Challis et al. 2001, 2005) and
other topics. Of relevance is the role of the placental genes in determining not only
the phenotype (size, morphology including ultrastructure, function, and so forth) for
the placenta per se, but for that of the fetus and its long-term programmed life
course as a newborn and adult (see below and Allen et al. 2002; Fowden 2003;
Fowden et al. 2006a, b; Heasman et al. 1999; Mellor 1983; Sibley et al. 1997, 2005;
Vaughan et al. 2011). These and other contemporary aspects of the biology of the
placenta are reviewed in the volume The Placenta and Human Developmental
Programming (Burton et al. 2011).
Of vital importance, during the past decade or so a considerable body of
evidence has demonstrated the role of imprinted genes, with their epigenetic
regulatory mechanisms, in normal cellular function. This includes the develop-
ment and differentiation of various facets of placental growth and metabolism, as
well as that for the fetus (Rahnama et al. 2006; Smith et al. 2006). Genomic
imprinting is the epigenetic-­mediated differential modification of the maternal and
paternal genetic contributions to the zygote, resulting in the differential expression
of parental alleles (e.g., one allele functioning with the other silenced) during
development and in the adult (Jablonka and Lamb 2002; Monk 1988; Murrell et al.
2005). Apparently unique to mammals, genetic imprinting is of particular impor-
tance in placental development (Ferguson-Smith et al. 2006; Frank et al. 2002;
Haig and Graham 1991; Li and Behringer 1998; Moore and Haig 1991; Zechner
et al. 2002). For the most part, paternally imprinted genes enhance, whereas mater-
nally expressed genes suppress, placental growth. The opposite is the case for fetal
tissues (Reik and Walter 2001; Tycko and Morison 2002). A majority of studies on
imprinted genes have been conducted in rodents (Hudson et al. 2010; Stadtfeld
et al. 2010).
Examples of imprinted genes that affect placental (and fetal) development
include the paternally expressed Igf2 (Baker et al. 1993), Mest, Peq1/Mest (Lefebvre
et al. 1998), Peg3 (Li et al. 1999), Phlda2/Ip1 (Frank et al. 2002), Ins1, and Ins2 and
others; several of which are clustered on mouse chromosome 7. Phlda/2 has been
shown to act as a rheostat for placental growth, with fetal IUGR following loss of
imprinting and overgrowth after gene deletion (Salas et al. 2004). Those maternally
expressed imprinted genes include: Igf 2r, H19, and Grb10 (Fowden et al. 2006a).
Targeted mutation of a paternally expressed imprinted gene has been shown to regu-
late multiple aspects of placental and fetal development (Curley et al. 2004; Drake
and Walker 2004; Reik 2007). The role of imprinted genes that regulate amino acid
transport in the murine placenta (Slc2a and Slc38a4), with genes that regulate
growth of the fetus (Igf2), also has been described (Constância et al. 2005). The
imprinted Igf-H19 complex plays a critical role in placental nutrient exchange by its
modulation of expression and activity of placental-specific amino acid transporters
(Fowden et al. 2006a). Of importance, placental imprinted gene products can modu-
late fetal nutrient supply and growth both by regulating optimal growth and
154 8  Some Aspects of the Physiology of the Placenta

development of all or part of the placenta, and by its exchange of nutrients. Examples
of genomic imprinting also include X-chromosome inactivation in female mammals
(Willard et al. 1993).

8.4  Pathology of the Placenta

Although this volume consists of a series of essays on physiology, pathologic

changes may lead to profound physiologic dysfunction. The vista of placental
pathology and its implications are reviewed in several volumes including Pathology
of the Human Placenta by Kurt Benirschke (Fig. 8.2d) and Shirley Driscoll, at that
time of the Dartmouth and Harvard Medical Schools, respectively (Benirschke and
Driscoll 1967; see also Benirschke 2002). Another valuable volume Pathology of
the Placenta was edited by Harold Fox (1931–2012) of the University of Manchester
(Fox 1978). In his Physiologie des Fötus, Friedrich Schatz presented in detail many
aspects of the twin to twin transfusion syndrome with its placental pathology and
consequences for the fetal pair (Schatz 1900) (Fig. 8.3). To a great degree, this 712
page volume consists of a series of papers that he had published previously in the
Archiv für Gynäkologie. It includes 34 full or double page plates, many in color,
which depict the placental vascular anatomy of monochorionic “identical” twins.
In his analysis, Schatz presented an idealized schema of the placenta with central
insertion of the umbilical cord, and in a meridian-like fashion the alternating
arteries and veins passing centrifugally to the placental margin. By performing
careful injections of different colored wax Schatz, recognized that most of these
cases had an umbilical arteriovenous anastomosis between the placental circula-
tions of the two infants. He demonstrated that in many instances branches of an
artery and vein would delve deep into the placenta, into what he termed a “third
circulation” through a “villous district” of the cotyledon. Usually these could not be
seen directly from the fetal surface. Schatz previously had reported on such a case
of placental anastomosis in twins (Schatz 1875), and later explored this concept
more fully (Schatz 1886; see Ludwig 2006).
In such cases the twin’s fate depends on the nature of these vascular connections,
with the recipient twin being grossly enlarged and edematous with elevated hemo-
globin concentration and hematocrit, enlarged organs, and a distended bladder. In
turn, the donor twin is small and shriveled with an empty bladder. Some of these
cases also demonstrated gross malformations. Because of the recipient twin’s ele-
vated urine output, these cases often are associated with maternal polyhydramnios
and the onset of premature labor (Benirschke 1958, 1961; Bergstedt 1957; Falkner
et al. 1962; Sacks 1959). In a series of reports, the pathologist Richard L. Naeye of
the University of Vermont has detailed many consequences for the fetus of the twin
to twin transfusion syndrome, including major differences in the relative sizes of
various body organs (Naeye 1963, 1964a, b, 1965). For instance, in a study among
five twin pairs born from 27 to 30 weeks gestation the body weight difference
between recipient and donor was 294 g. For two pairs born near-term, this
8.4  Pathology of the Placenta 155

Fig. 8.3 (a) Friedrich Schatz (1841-1920) (b) Title Page of Physiologie des Fötus, 1900 (c) Plates
illustrating placental anatomy in instances of vascular anastomosis (circled) in placentas of two
sets of monochorionic “identical”twins

difference averaged 847 g (Naeye 1963). The recipient twin also demonstrated
greater muscle mass about both pulmonary and systemic arteries, as well as signifi-
cantly larger renal glomeruli (Naeye 1963). In another report of ten such twin pairs
from 23 to 30 weeks gestation (which included several pairs from the previous
report), not only was there a discordance of about 200 g in body weight, but signifi-
cant weight differences were seen in the brain, heart, lungs, liver, and other organs.
At the cellular level the number and size of cardiac myocytes were increased signifi-
cantly in the recipient twin (Naeye 1965). Twin to twin transfusion syndrome has
been identified as the most important determinant of growth disparity between iden-
tical twins.
Challenges for the future include the use of advanced microscopy to allow further
understanding of the ultrastructure of the human placenta and that of other species.
156 8  Some Aspects of the Physiology of the Placenta

Advances in genomics, epigenomics, and proteomics will see greater understanding

of the metabolic, hormonal, immunologic, and other aspects of placentology, and
the role that imprinting and these functions play in embryonic and fetal develop-
ment. Only as endocrinologists, physiologists, biochemists, cellular and molecular
biologists, and other scientists work to untangle the “Placental Maze” (Corner 1963),
from the nuances of implantation to full development, will we come to a deeper
understanding of the mysteries and wonders of the development and function of that
wondrous “Bundle of Life” and “External Soul” (Longo and Reynolds 2010).

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Chapter 9
Governmental Support of Research in Fetal
and Newborn Physiology

9.1 The Medical Research Council of Great Britain

To support the investigators who labor to advance knowledge in a given field of

scientific research, a critical element is that of the financial resources for such
endeavors. In the earliest years of experimental investigation, the occasional King
and other patron gave of their largesse to support the William Harveys and his ilk.
Contributing to the advancement of science in a significant manner, such support
was limited and irregular (Frank 1980). In Great Britain, it was in the mid- to late-
nineteenth century that the predecessors of the Medical Research Council (MRC)
developed. At this time, tuberculosis was one of the nation’s chief health problems.
In 1901, a “Royal Commission Appointed to Inquire into the Relations of Human
and Animal Tuberculosis” was established under the chairmanship of Sir Michael
Foster, professor of physiology at the University of Cambridge, to determine
whether the disease was the same in the several species, and the extent to which they
could infect one another. In a large part, and with recognition of the German and
French governmental-sponsorship research to advances in medicine and healthcare,
this study helped to crystallize in the minds of many leaders, political as well as
academic, the concept that the promotion of medical research is a responsibility of
the state. In 1891, “The British Institute of Preventative Medicine” had been estab-
lished in London. In 1903, this title was changed to “The Lister Institute of
Preventative Medicine.” The National Insurance Act of 1911 stipulated that research
not be limited to tuberculosis, and 2 years later (1913) a Medical Research
Committee was established. The change to the Committee was,
The duties of the Committee will be to formulate the general plan of research and enquiry
at the outset, and for each year to make arrangements for carrying it out, and to supervise
its conduct so far as may be necessary, and in particular to secure adequate coordination of
the various parts of the scheme. It will also deal with the collection and publication of infor-
mation and of the results of statistical and other enquiries so far as suitable or necessary. For
this purpose it will determine, subject to the assent of the Minister responsible for National
Health Insurance, the expenditure of the money available each year; the total of the sums
available … being about £57 000 per annum. Before the Minister responsible for National

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 167
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_9, © American Physiological Society 2013
168 9 Governmental Support of Research in Fetal and Newborn Physiology

Health Insurance gives his final assent to the scheme of the Medical Research Committee
for any year, he will receive criticisms and suggestions in regard to it from the Advisory
Council for Research, which is being appointed for this purpose.
(Thomson 1973, p. 22)

Within a few months, the Committee, under the chairmanship of John Fletcher
Moulton (Lord Moulton; 1844–1921), had developed a “Scheme of Research” for
“… the extension of medical knowledge with the view of increasing our powers of
preserving health and preventing or combating disease…” (Thomson 1973, p. 28).
From its beginning, the Medical Research Committee sought to support both basic
and clinical research. In terms of the latter, one must understand that prior to World
War I, the schools of medicine, particularly those in London, were private institu-
tions, and there was little encouragement for research of a clinical nature (Booth
1989, 2003).
A key element of progress, and a foundation upon which medical research in
Britain was to thrive, following establishment of the proposal of Lord Chancellor
Haldane, the “Haldane Principle,” e.g., that scientific decisions regarding research
proposals were to be made independent of governmental intervention (Thomson
1973, p. 41). At the end of the “Great War,” the Committee acknowledged “… the
urgent importance of using the resources of the Medical Research Fund to forward
the science of experimental medicine and its study at the bedside in close conjunc-
tion with all of the resources of the modern laboratory” (MRC 1919, p. 28). Because
of the lack of structured university-hospital alliance, and few physician-scientists to
lead out in research in experimental medicine, it would be a decade or more before
these ideals would be realized. In large part, it was the combined influence of pre-
clinical scientists working with their clinically oriented allies, who advanced state
funding for medical research. With the appointment of a Medical Advisory
Committee in 1929, the funding of centers of clinical research increased to support
the flourishing of clinical investigation. As chair of the “Royal Commission on
University Education in London,” Lord Haldane previously had made a vital contri-
bution. This was the report (1913) noted earlier, that recommended the initiation of
changes that would lead to the establishment of contemporary academic depart-
ments of medicine and other clinical subjects, in which there was an appropriate
emphasis on research (Royal Commission on University Education 1913).
A year following passage of a Ministry of Health Act (1919), the Medical
Research Committee was reconstituted into the independent Medical Research
Council, with a Royal Charter and a modest budget for “purposes of research,” and
an Institute was established at Hampstead in north London for clinical research.
During the two decades 1914–1933, the MRC was chaired by Sir Walter Morley
Fletcher, a physician-physiologist and Fellow of the Royal Society. Fletcher stressed
the importance of both the basic sciences and clinical research to the advancement
of medicine, and played a key role in furthering medical research in the UK
Fletcher’s successor as MRC Secretary, Edward Mellanby (later Sir Edward; 1884–
1955), a pioneer in the study of rickets, also was a staunch supporter of clinical
investigation, and urged furtherance of studies on the nutritional basis of health and
disease. Despite the considerable evidence from experimental studies, contrary
9.1 The Medical Research Council of Great Britain 169

views by some members of the UK Ministry of Health resulted in less than full com-
mitment to the pursuit of nutritional studies (Petty 1989).
During the 1930s, the MRC provided funds for specific projects, as well as work-
ing to establish full-time academic positions at a number of medical schools
throughout the UK (Booth 2003). Another field to which the MRC devoted consid-
erable support was that of experimental radiology. Although to a great extent the
focus of this support was on the biologic effects of radiation, it included studies in
diagnostic radiology such as that of Alfred E. Barclay (Cantor 1989). In the imme-
diate post-World War II era, the MRC supported two vital studies that changed the
progress of clinical research. An important concept of the MRC “Scheme of
Research” was to engage in “all statistical investigations useful either as prelimi-
nary to research or confirmatory of its results.” These included “enquiries relating to
diet, occupation, habits of life and other matters bearing upon the incidence of dis-
ease,” and to “collect and deal with all types of vital statistics,” including those with
an epidemiological bearing (Thomson 1973, p. 114). As is widely appreciated, con-
temporary statistics is the science of learning from data, and of measuring, control-
ling, and communicating uncertainty. Thereby, statistics provides the critical
navigation essential for supporting the advances in science and of society. A MRC
grantee of note who developed the field of statistics, was Karl Pearson (1857–1936)
of the London School of Hygiene and Tropical Medicine, University College,
London. Pearson’s group included the noted biostatistician George Udny Yule
(1871–1951), in concert with Sir Francis Galton (1822–1911) (Hill 1937).
Another key figure in the development of statistics for the biological sciences,
was Ronald Aylmer Fisher (later Sir Ronald; 1890–1962), who spent a decade and
a half at the Rothamsted Experimental Station, located in Hertfordshire. Here,
Fisher introduced the concept of random allocation of compared treatments to
improve crop yields in agricultural research. Such analysis permitted chance to
operate freely, thus allowing calculation of reasonable estimates of effect-size in a
single growing season (Fisher 1926). This format of randomized-control trial over-
came the limitations of traditional methods of data collection, which could require
many years. An example of the value of the randomized controlled clinical trial was
that by Austin Bradford Hill (later Sir Bradford; 1897–1991) which established the
efficacy of streptomycin in the treatment of pulmonary tuberculosis (Streptomycin
in Tuberculosis Trials Committee 1948). Another important study was the applica-
tion of epidemiology to a clinical problem, e.g., the demonstration by Bradford Hill
and William Richard Shaboe Doll (later Sir Richard; 1912–2005) on the relation of
smoking cigarettes to lung cancer (Doll and Hill 1950). Although Fisher’s, Hill’s
and the others’ approaches revolutionized research in many fields of science, sev-
eral decades elapsed before this methodology was adopted into clinical medicine. In
a prescient essay on the value of biostatistics in clinical and preventive medicine, Sir
Austin Bradford Hill observed,
… the physician’s first duty is to his patient—to do all in his power to save the patient’s life
and restore him, as rapidly as possible, to health. That fundamental and ethical duty must
never be overlooked—though with the introduction of better, brighter and ever more toxic
drugs, and with the wide prevalence of surgical procedures … the onlooker may perhaps
170 9 Governmental Support of Research in Fetal and Newborn Physiology

with good reason sometimes ask the clinician ‘are you sure you know where that duty lies?’
It seems to me sometimes to be unethical not to experiment, not to carry out a controlled
clinical trial.
(Hill 1962, p. 30)

Together these mathematically minded biometricians, whose chief interest at the

time was the study of heredity and eugenics, revolutionized experimental science.
With the use of mathematical methods, they invented the concepts of testing the null
hypothesis, degrees of freedom, regression analysis, the correlation coefficient,
analysis of variance, the chi-square test of statistical significance, and others that
helped to develop the discipline we know as biostatistics (Higgs 2000). Also impor-
tantly, for clinical and basic science investigators, the creation of these methodolo-
gies has proven time and again the superior power of the experimental over the
observational approach to the evaluation and interpretation of data and/or the results
of a given therapy.
In 1916, the Medical Research Commission, at the urging of Osler and several
others, had recruited Thomas Lewis (later Sir Thomas; 1881–1945) (Fig. 9.1a) as
their first full time investigator. A pioneer in cardiology and electromyography,
Lewis later headed a MRC supported Department of Clinical Research and
Experimental Medicine at the University College Hospital, London. Of importance
to biomedical research, Lewis was one of the architects of clinical research in all of
Great Britain. By the early 1930s he was one of the most influential British acade-
micians in this field (Lewis 1933), founding the Medical Research Society (1930).
In his 1935 Thomas H. Huxley address, “… Clinical Science within the University,”
given at the University of Birmingham, Sir Thomas quoted Sir James Paget (1814–
1899) in stressing the importance of clinical research,
I feel sure that clinical science has as good a claim to the name and rights and self-
subsistence of a science as any other department of biology; and that in it are the safest and
best means of increasing the knowledge of diseases and their treatment. … Receiving
thankfully all the help that physiology or chemistry or any other sciences more advanced
than our own can give us, and pursuing all our studies with the precision and circumspec-
tion that we may best learn from them, let us still hold that, within our range of study, that
alone is true which is proved clinically, and that which is clinically proved needs no other
evidence.
(Lewis 1935, p. 631; Booth 2003)

Nonetheless, some have held that during its early years, the MRC record of sup-
port for research in medicine was rather uneven (see Hamilton 2004; Timmermann
2008). Much of its funding was based on “word of mouth” recommendation for
those in favor, rather than formal peer review (Boyd and Boyd 2010). Some out-
standing early members of Council, and investigators supported by the MRC,
included Sir Charles Scott Sherrington (1857–1952), Sir Frederick Gowland
Hopkins (1861–1947), Sir Henry Hallett Dale (1875–1968), First Baron Edgar
Douglas Adrian (1889–1977), Baron Howard Walter Florey (1898–1968), each of
whom was a Nobel Laureate (Thomson 1973–1975). Sir Hans Adolph Krebs
(1900–1981) in his address “The Making of a Scientist” emphasized the critical role
of the Medical Research Council in supporting first-rate investigators in Britain, a
number of whom became Nobel Laureates (Krebs 1967).
9.1 The Medical Research Council of Great Britain 171

Fig. 9.1 (a) Sir Thomas Lewis (1881–1945). (b) Chester Bryant Stewart (1910–1999). (c) Senator
Joseph Eugene Ransdell (1858–1954). (d) Vannevar Bush (1890–1974)

Several historians have considered in detail aspects of the MRC and its support
for biomedical research, both basic and clinical (MacNalty 1948), as well as educa-
tion (Poynter 1966). Specific contributions include establishment of the Royal
Postgraduate Medical School (incorporated 1931, opened 1935) at the Hammersmith
Hospital, London, which, in addition to its role as a teaching institution, had as its
goal “… the pursuit of research and advance of medical knowledge” (Booth 1985, p.
1771; Newman 1966). Another MRC contribution of note was the establishment in
1947 of the “Unit for Research on the Molecular Structure of Biological Systems,”
currently the “MRC Laboratory of Molecular Biology” at Cambridge University.
Following passage of the National Health Services Act in 1948, clinical research
expanded greatly. The Northwick Park Institute for Clinical Research near Harrow
172 9 Governmental Support of Research in Fetal and Newborn Physiology

(founded in 1994) was in part funded by the MRC. (See Austoker and Bryder 1989;
Booth 1985, 1986, 2003; Newman 1966; Thomson 1973–1975; Timmermann 2008).

9.2 The Medical Research Councils of Canada and Australia

In Canada, the Medical Research Council, modeled after that in the UK, had its
beginnings in 1916. As chairman of the MRC Medical Research Committee, in
1938, Sir Frederick Grant Banting (1891–1941; who with Charles Herbert Best
(1899–1978) codiscovered insulin), and Chester Bryant Stewart (1910–1999)
(Fig. 9.1b) traveled throughout Canada, meeting with over 300 medical researchers
from Halifax, Nova Scotia, to Vancouver, British Columbia, to assess the state of
Canadian biomedical science. The goal of this pilgrimage was to establish, more
firmly, medical research throughout the provinces. To their dismay, however, in
institutions other than McGill University and the University of Toronto, Banting
and Stewart discovered a dearth of facilities, funding, or other infrastructure required
for successful laboratory or clinical research. The Banting and Stewart report was of
importance in establishing a knowledge base, upon which recommendations for
increased and more systematic support could be sustained. In 1939, with the inter-
ruption of World War II, however, the schemes for improved organization had to be
placed on hold. In returning to this issue following the war, in 1958, the Canadian
Privy Council appointed a special committee under the chairmanship of the promi-
nent physician-scientist Ray Fletcher Farquharson (1887–1965), to revive increased
extramural support for medical research. At the heart of the Farquharson Commission
discussions were the issues of how to nurture young Canadian medical scientists,
and to support the work of established investigators. To what extent could the
Dominion government provide for medical science? How would government sup-
port fit into the landscape of research funding, alongside other government minis-
tries, and that of private philanthropy and the work of voluntary organizations?
In light of the continued state of discontinuity in resources and funding, in 1960
under the leadership of Farquharson, the independent Canadian Medical Research
Council was founded, which would fund fundamental research in the basic bio-
medical sciences, as well as translational and clinical research. Farquharson noted
“most important of all is the great expansion of medical research which follows in
the wake of every advance. Each new discovery leads to further discovery; each
advance in treatment throws new light on the fundamental nature of the affected
disorder, demanding further investigation. Every new treatment whether successful
or not is potentially dangerous, creating new problems” (Medical Research Council
of Canada 2000, p. 15). In 2000, the Canadian MRC was transformed into the
Institutes of Health Research, as the governmental agency responsible for all health
research. With establishment of 13 “virtual” institutes throughout the Provinces, in
part, its mission was to increase funding for more research on targeted priority
areas; build research capacity in under-developed areas such as population health
and health services research; train a new generation of health researchers; and focus
9.3 The US National Institutes of Health 173

on knowledge translation, so that the results of research would be transformed into

policies, practices, procedures, products, and services. Under the leadership of sev-
eral outstanding scientists, the Canadian Institutes of Health Research has contin-
ued to grow, and the establishment of major centers of fetal and neonatal physiology,
perinatology, and neonatology with world class scientists, attest to that commitment
(http://www.cihr.ca).
In Australia, upon recommendation of a Royal Commission, the Federal Health
Council was established in 1926, and a decade later, in 1937 the National Health
and Medical Research Council was founded. In part, because of Australia’s expan-
sive enterprise in sheep farming, the MRC made major investments in veterinary
medicine research, much of which concerned reproduction and the biology of the
fetus and newborn.

9.3 The US National Institutes of Health

During the nineteenth century epidemics of Asiatic cholera and yellow fever swept
across the USA. It was not until the latter part of the century, however, that the gov-
ernment recognized the need for a national laboratory to study these and other infec-
tious diseases such as smallpox and tuberculosis. Thus, federally funded research
originated in 1887, with formation of the Laboratory of Hygiene in the Marine
Hospital Service on Staten Island, New York. Joseph James Kinyoun (1860–1919),
a microbiologist was the sole investigator. With advancements in understanding the
role of microbes in human disease, its original mission was to eliminate infectious
diseases. Congressional legislation expanded the laboratory in 1902, with divisions
of chemistry and zoology. By 1912, when the Hygiene Laboratory had reached the
maturity of a quarter of a century, it had moved to new facilities at 25th and E
Streets in Washington, D.C. Its name had been changed to the Public Health Service
Laboratory, and its research programs expanded to include diseases other than those
that were communicable. This led to creation of related federal agencies such as the
US Food and Drug Administration (1906) and the Centers for Disease Control
(1946) (originally the Communicable Disease Center).
Without doubt, the transformation in the role of the federal government in eco-
nomic and social aspects of national affairs that occurred during the depression era
of the 1930s, constituted a broad underlying aspect of the role of government in the
major advances in public health and medical research that followed. For example,
this transition in national concern set the stage for the legislation with great conse-
quence for mothers and their children. In the Social Security Act of 1935, with the
support of physicians and his wife Anna Eleanor (1884–1962), President Franklin
Delano Roosevelt (1882–1945) included Title V that enabled the federal govern-
ment to fund state programs for maternal and child heath units and services for
crippled children. Two years later in 1937, not only was the Public Health Service
Research Program 50 years old, but it had been reorganized into the National
Institute of Health (NIH). This imaginative and far-reaching legislation occurred
174 9 Governmental Support of Research in Fetal and Newborn Physiology

largely as a result of Louisiana Senator Joseph Eugene Ransdell (1858–1954)

(Fig. 9.1c), whose bill to create the Institute to focus on the fundamental problems
of the diseases of man was passed by Congress in 1930, and signed by President
Herbert Clark Hoover (1874–1964). During these early years, the chief emphasis of
the NIH were studies on infectious disease and cancer. By mid-decade, the National
Institute of Health was experiencing a shortage of space, in particular requiring
quarters for housing research animals. About this time, a wealthy entrepreneur and
philanthropist, Luke Ingalls Wilson (1872–1937) had offered the US State
Department his magnificent estate, “Treetops” adjoining the Rockville Pike in
Bethesda, MD, as a site for an institute to promote peace. This being of little interest
to the State Department, then Surgeon General Thomas Parran (1892–1968) urged
President Roosevelt to accept this windfall for the NIH, and to allocate funds to
construct the original three campus buildings. Lewis Ryers Thompson (1883–1954),
who had served as Assistant Surgeon General was appointed the first Director of
this newly reorganized NIH. In 1937, construction commenced on the Bethesda
campus. With passage of the National Cancer Act by Congress that year, the
National Cancer Institute was created, and paradoxically Wilson died of cancer
soon thereafter. With establishment of this new Institute, the NIH became the
National Institutes of Health. Medical research advanced not only at Bethesda, but
grants-in-aid were provided to scientists at nonfederal institutions. (For the History
of the NIH to 1937, see Harden 1986).
During the early 1940s, with the trauma and horrors of World War II, national
attention and energies were diverted to a greater cause, the preservation of a free
society. The evils of war were not without limited good effect, however. In 1944,
Title III of the Public Health Service Act (Public Law 410) provided the US Surgeon
General to foster, conduct, support, and cooperate in wide-ranging research related
to health and disease. Thus, the award of grants for nonfederal research and research
training was extended beyond cancer to other health problems. An additional
advance that eventuated from the war effort was establishment of the Office of
Scientific Research and Development to coordinate and contract University-based
research. This collaboration of the federal government with the nation’s institutions
of higher learning demonstrated the contributions to national problems such an alli-
ance could achieve. With success of the Manhattan Project, the invention of radar,
the commercial production of penicillin, and many other achievements, the contri-
butions of science and technology generated high expectations for the solution of
problems of national scope.
In late 1944, prior to the end of World War II, President Roosevelt contacted
Vannevar Bush, a PhD (Fig. 9.1d) in electrical engineering who served as his Science
Advisor and director of the Wartime OSRD, for his ideas on what the government
might do to further research by public and private institutions. In response, Bush
distilled the lessons of the wartime mobilization, outlining his visionary policies for
the federal support of peace-time health and other research in his Science—The
Endless Frontier (Bush 1945). This marked the beginning of modern-day govern-
mental science policy. Bush foresaw both the vital need for government’s support of
fundamental biomedical research, and the key role that the nation’s universities and
9.3 The US National Institutes of Health 175

colleges could play in advancing knowledge in the health sciences by letting minds
explore. In this analysis Bush proposed “Five Fundamentals” or basic principles,
that he believed must guide governmental support of civilian research, to achieve
progress towards national goals in science, health, defense, and the economy. These
included: emphasis on basic research, stability of funding for 5 or more years for the
support of long-term programs, oversight administration by citizens committed to
promotion of the work of a given agency, independence of the grantee institutions
themselves with internal administrative control of policies and administration, and
the scope of research performed must remain responsible and accountable to the
President and to Congress. In following these principles, the several agencies have
made a lasting contribution and legacy. Bush played an advisory role in the organi-
zation of scientific talent and resources into national laboratories that continued far
beyond the war years. He worked to develop grant funding mechanisms to support
university scientists and their research, without the heavy hand of governmental
interference. Rather than conceptualize the science per se, Bush helped to create the
organizations that supported and advanced science.
With termination of the wartime OSRD, university biomedical contracts were
transferred to the NIH, while those in the physical sciences were placed under the
aegis of the Office of Naval Research (ONR). In 1950, with passage of the National
Science Foundation (NSF) Act (Public Law 81-507), those OSRD programs of NIH
and ONR not relating to health were transferred to the newly founded NSF. The
following year (1951), the physicist and former OSRD director of field operations,
Alan Tower Waterman (1892–1967) was appointed first director of NSF, a role in
which he devoted his energies to ensure that the Foundation became one of the
world’s finest government-supported organizations devoted to promotion of excel-
lence in scientific research and education. Upon retiring from that position in 1963,
Waterman was awarded the National Medal of Freedom.
It was in the late 1940s that national leaders conceived the concept of a highly
focused effort to solve diseases of major impact on the nation’s health. Following
passage of the Mental Health Act of 1946, authorization was given for the National
Institute of Dental Research and the National Heart Institute (1948). Passage of an
“Omnibus Act” in 1950, empowered the US Surgeon General Leonard Andrew
Scheele (1907–1993; Surgeon General from 1948 to 1956) to establish several other
disease-identified institutes including those for Neurological Disease and Blindness,
Experimental Biology and Medicine (later renamed Arthritis and Metabolic
Diseases) and Microbiological Institute (predecessor to Allergy and Infectious
Diseases). With its broadened mandate, the NIH could address the basic and clinical
aspects of health and disease on a wide front. Scheele later served as President of
the World Health Organization.
In 1948 construction on the major building of the NIH Clinical Center commenced,
and by 1953 it was completed to house a unique, world-class program of intramural
basic, translational, and clinical research developed both to understand and to treat,
beyond infectious disease and cancer, a number of diseases that plague society.
Chiseled on the portals of the Clinical Center are the words of Jack Masur (1908–
1969), designer and first director of that center from 1948 to 1951 and 1956 to 1969,
176 9 Governmental Support of Research in Fetal and Newborn Physiology

Fig. 9.2 (a) James Augustine Shannon (1904–1994). (b) Senator Joseph Lister Hill (1894–1984).
(c) Congressman John Edward Fogarty (1913–1967). (d) Mary (1900–1994) and Albert Lasker
(1880–1952)

Hospitals with long traditions of excellence have demonstrated abundantly that Research
enhances the vitality of Teaching. Teaching lifts the standards of Service, and Service opens
new avenues of Investigation.
(see Longo 1988, p. 6)

Critical to the development of biomedical science, with growth of the NIH bud-
get during this era, was enthusiastic support by the US Congress of the concept of
research leading to the amelioration of disease and improvement of the health of
Americans. A key player in this growth with its exponential increase in influence of
the NIH was James Augustine Shannon (1904–1994) (Fig. 9.2a), director from 1955
until his mandatory retirement in 1968. An M.D., Ph.D. in physiology, who during
World War II led a research group, and subsequently served as director of medical
research and corporate vice-president of a major pharmaceutical company, Shannon
had considerable insight into the potential and strength of biomedical research, evi-
denced, in part, by the number of gifted scientists and physician-scientists whom he
attracted to the NIH. He also had a great gift to communicate this promise to
Presidents and leaders in Congress, who enacted the legislation required to support
this expanded enterprise (Kennedy 1998). Under Shannon’s leadership, America
9.3 The US National Institutes of Health 177

saw a “Golden Age” of biomedical research. In addition to growth in the intra-mural

research program, Shannon oversaw an almost exponential increase in support of
extra-mural research grant programs, and the establishment of problem-focused
study sections to develop and sustain quality and relevance of research proposals
through rigorous peer review (Hannaway 2008). Working with the US Secretary of
the Department of Health, Education, and Welfare, Marion Bayard Folsom (1893–
1976) and Congress, the 1956 Health Research Facilities Construction Act (PL
84-835) expanded construction of medical research facilities at a number of
University Medical centers to expand research capacity in the life sciences.
Importantly, Shannon with the support of Secretary Folsom also cultivated its train-
ing and mentoring programs for the education of scientists and physician-scientists,
including the Medical Scientist Training Program for MD-PhDs and Research
Career Development Awards for young investigators. These awards transformed
academic medicine to a profession that strove for supreme excellence in basic and
clinical research, teaching, and patient care. Shannon later characterized these con-
tributions as products of a “republic of science” (Shannon 1967, p. 100).
In his 1967 Alan Gregg (1890–1957) Memorial Lecture delivered to the
Association of American Medical Colleges, Shannon recounted the role of the NIH
in advancement of biomedical research and the health of Americans. He noted the
need to maintain research on the cutting edge of science, the requirement to balance
research and education, issues relating to the problems of academic centers in adapt-
ing to becoming major centers of research and their institutional responsibilities, the
need to maintain an optimal environment for the advancement of medical knowl-
edge, to devising mechanisms for continued long-term support, and ensure that
medical education reflects the progress in science and understanding (Shannon
1967). For his many contributions, including those of research on antimalarial drugs
during World War II, Shannon was awarded the Presidential Medal of Merit (1948).
He also received the Public Welfare Medal of the National Academy of Sciences
(1962) and the National Medal of Science (1974). He is recognized by having the
NIH Administrative Center (Building 1) named in his honor. Thomas J. Kennedy,
Jr. has written of Shannon,
Virtually none of today’s active scientists have had any experience with the environment
that prevailed in the world of biomedical research in the pre-Shannon era. In fact, there is
hardly a person now alive who remembers…. But the institution to whose structure, func-
tion, growth, and development he added such a powerful impetus has in the four or so
decades since he became its director changed the face of biological and medical science,
medical practice, and human health almost beyond recognition.… Virtually every individ-
ual who ever worked closely with Jim Shannon remembered him as a heroic figure and
almost unanimously rated their associations with him as the most enriching and memorable
of their careers.
(Kennedy 1998, pp. 373–374)

Much has been written about the concatenation of events that transpired during
Shannon’s tenure at the NIH. In part, because leaders in the Executive branch of the
US government displayed little enthusiasm for this nation’s commitment to the
improvement of health-care-directed research, two leaders in the Legislative Branch
178 9 Governmental Support of Research in Fetal and Newborn Physiology

seized the day. Senator Joseph Lister Hill (1894–1984) (D-Alabama) (Fig. 9.2b),
chair of the Labor and Public Works Committee as well as its Health Subcommittee,
and later of the Appropriations Subcommittee with jurisdiction of education, labor,
and health, became known as the “… statesman for health” (Schaefer 1968). His
colleague Congressman John Edward Fogarty (1913–1967) (D-Rhode Island) (Fig.
9.2c), also became chair of the subcommittee for Labor, Health, and Education of
the House Appropriations Committee. Together with Hill they became effective
champions of medical research, and during their tenure the NIH budget and its over-
all research program blossomed (Schaefer 1968). Fogarty is honored by the NIH
“John E. Fogarty International Center for Advanced Study in the Health Sciences.”
Hill, who in addition to many other pieces of legislation co-sponsored the 1956 bill
to transfer the National Library of Medicine to the NIH, is commemorated in the
NIH Lister Hill National Center for Biomedical Communications at the National
Library of Medicine. Regarding Fogarty and Hill, Shannon has written “The nation
owes much to their courage, devotion, and skill” (Shannon 1967, p. 102).
Another key player in advancing an agenda for biomedical research, and advo-
cate in the “health syndicate,” was the politically connected, New York philanthro-
pist and health activist Mary Woodard Lasker (1900–1994), who with brains,
energy, and charm mobilized considerable support for biomedical research. In 1942,
she, with her husband and advertising executive Albert Davis Lasker (1880–1952)
(Fig. 9.2d), established the Albert and Mary Lasker Foundation to raise awareness
of major diseases, and their need for greater funding for research. An able spokes-
woman and catalyst, Mrs. Lasker lobbied Presidents and Congressional leaders for
funding for major diseases. Initially concentrating on cancer, mental health, and
birth control, later, she expanded their agenda to include cardiovascular disease,
hypertension, and arthritis. Together, the Laskers also played an important role in
reorganizing the American Cancer Society to enlarge its public fundraising, public-
ity, and lobbying efforts. Mary Lasker received both the Presidential Medal of
Freedom, the Nation’s highest civilian honor (1969), and the Congressional Gold
Medal (1989). The Lasker Awards of the Albert and Mary Lasker Foundation are a
tribute to their legacy.
With an expanding social agenda, by 1961 a Center for Research in Child Health
had been established in the Division of General Medical Sciences of the NIH.
In addition, that year a task force had reported to President John Fitzgerald Kennedy
(1917–1963) that research into the physical, intellectual, and emotional growth of
children was severely handicapped by not having a centralized organizational struc-
ture. The group called for a new institute to launch a concentrated attack against
disorders of development. Because at that time, by law, each institute had as its mis-
sion to increase understanding and to develop treatments for specific diseases, new
laws had to be written and enacted. Thus on 17 October 1962, near the 75th birthday
of the (by then designated) National Institutes of Health, Public Law 87-838 was
passed, which authorized creation of the National Institute of Child Health and
Human Development (NICHD), with a mandate to conduct research and training
relating to maternal health, child health, and human development, and the National
Institute of General Medical Sciences. A few months later the National Institute of
9.3 The US National Institutes of Health 179

Child Health and Human Development was physically established (Longo 1988). It
is almost beyond comprehension to encompass and appreciate the good which has
eventuated as a consequence of the founding and funding of the NICHD. In 2008,
this was renamed the Eunice Kennedy Shriver National Institute of Child Health
and Human Development to honor President Kennedy’s older sister Eunice
Kennedy (1921–2009), who had played a critical role in urging her brother, at that
time who was not enthusiastic about the idea, that the improvements in health that
would result from establishment of such an Institute would far exceed the initial
costs required to bring them about (http://www.nichd.nih.gov/news/releases/
eks_030308.cfm).
The year following founding the NICHD, President Kennedy became particu-
larly mindful of the importance of research on the fetus and newborn. For it was at
that time, 7 August 1963, that his son Patrick Bouvier was born by cesarean sec-
tion at ~34 weeks gestation (2.1 kg). With “hyaline membrane disease” (respira-
tory distress syndrome; see below), the infant was transferred to the Boston
Children’s Hospital Medical Center for treatment in a high pressure oxygen cham-
ber. Although initially the infant appeared to improve, despite heroic efforts he
died 2 days following delivery. A related development of clinical relevance, was
the 1965 legislation to establish maternal and infant care programs. With establish-
ment of children and youth clinics, comprehensive health services were provided
to a high percentage of all children. In concert with societal mandate for improved
clinical care, the NICHD increased its funding for training and education in
research. Of importance to the field of fetal and neonatal physiology for the educa-
tion of obstetrical gynecology physician-scientists, this included support for the
Reproductive Scientist Development Program (Longo et al. 1999; Longo and Jaffe
2008) and for their counterparts in Pediatrics, the Pediatric Scientist Development
Program (Hostetter 2002).
An additional vital milestone, was that in 1968 of the National Library of
Medicine (NLM) becoming a component of the NIH. With its on-line databases
being accessible to scientists throughout the world, the NLM developed into the
world’s foremost biomedical communications resource. As has been observed by
others, the decades since the end of World War II have seen the NIH expand into
the premier biomedical research facility in the USA and the world. It is a noble
and distinguished legacy of the manner in which governmental support of both
fundamental and translational/clinical research has contributed to the betterment
of humankind. As was observed by one individual in his testimony before a
United States Congressional Committee, “If we did not have the NIH we would
have to invent it … [it] is one of the truly remarkable social inventions of the
ages” (Bock 1980).
Several reports have reviewed the NIH contributions to science and the chal-
lenges in its maintenance of preeminence in biomedical research (Association of
American Medical Colleges 1983; Harden 1986; Stetten and Carrigan 1984; Turner
1967). In commenting upon the NIH and its contributions to life, the essayist and
former Dean of the Yale and New York University Schools of Medicine, Lewis
Thomas (1913–1993) observed
180 9 Governmental Support of Research in Fetal and Newborn Physiology

… it lifts the heart to look closely at one institution created by the United States Government
which has been achieving, since its onset, one spectacular, stunning success after another.
The National Institutes of Health … is one of this nation’s great treasures. As social inven-
tions for human betterment go, this one is standing proof that, at least once in a while,
government possesses the capacity to do something unique, imaginative, useful, and alto-
gether right.
(Thomas 1984, p. xvii)

Of importance, each of these funding institutions, British, Canadian, Australian,

American, and others, constitutes a vital organism in which the whole is greater
than the sum of its parts. Each has a corporate existence that involves contributions
by a large number of individuals, has a momentum that transcends individuals
themselves, is a corporate body which anyone would be honored to serve, but which
no one can claim as its own. As demonstrated by considerable evidence it is through
national scientific organizations such as the MRC, the NIH, and others, and their
support for individual grants for biomedical research, large program and center
grants, training grants, predoctoral and postdoctoral scholarships, awards for sab-
baticals, and other mechanisms, that progress in the scientific basis of medicine and
health has been assured.

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Chapter 10
Fetal–Neonatal Growth and Metabolism

10.1 Early Studies

In his essay “On being the right size,” the British geneticist, biometrician, and popu-
larizer of science John Burdon Sanderson (JBS) Haldane (1892–1964) theorized on
and presented some mathematical analysis for the optimal size of various organisms.
In addition to consideration of body mass, he included surface area, weight-bearing
bone structure, respiratory and circulating mechanisms, and other features of com-
parative anatomy and physiology (Haldane 1927). His analysis extended from
insects to birds, to a number of mammals which varied in size from mice to the rhi-
noceros. Haldane concluded “… that for every type of animal there is an optimal
size” (Haldane 1927, p. 18). A number of studies have disclosed that even for the
fetus development follows clearly defined mathematical principles (Roberts 1906;
see below). Quite obviously, essential to a successful pregnancy is the optimal
growth and development of the embryo-fetus. Prior to full maturity, timely growth,
both physical and mental, is one of the best indicators of a fully functional physio-
logical system and health. As is appreciated, growth of the fetus and its various
organs is a complex process that is a function of genetic endowment, state of mater-
nal health, the availability of nutrients and oxygen, as well as a multitude of growth
factors and hormones of maternal, placental, and fetal origin, as well as a host of
environmental factors of epigenetic influence. These factors are associated with
physiologic, biochemical, and molecular changes, most of which are only poorly
understood (Cheek 1975; Timiras 1972; Winick 1972). From mid-century onward,
considerable emphasis has been placed on the mechanisms of cell division and mul-
tiplication (hyperplasia) and cell enlargement with cytoplasmic growth (hypertro-
phy) that result in the deposition of new tissue and change in anatomical form (Cheek
1975; Cockburn 1988; Fowden 1989; Winick 1972; Winick and Noble 1965).
In the late-nineteenth century, the developmental embryologist/anatomist Charles
S. Minot noted that from conception to maturity, guinea pigs grow at a rate of
1.8 g·day−1, rabbits at 6.3 g·day−1, and humans at 6.7 g·day−1 (Minot 1891). Humans
grow much larger than rabbits because they grow for a longer length of time; however,

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 183
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_10, © American Physiological Society 2013
184 10 Fetal–Neonatal Growth and Metabolism

rabbits grow larger than guinea pigs because they grow at a more rapid rate. This was
the first numerical demonstration of the differing manners by which one could attain
a given mass and size. A philosopher of science, Minot stressed that, “The proper
object, the final purpose of Biology, is the discovery of the nature and laws of life”
(Minot 1891, p. 97). Along this line, he worked to discover the fundamental properties
of living organisms and establish the implausibility of vitalism (see below). Minot
stated what he called the law of cytomorphosis (now termed morphogenesis), “… to
designate comprehensively all of the structural alterations which cells, or successive
generations of cells, may undergo from the earliest undifferentiated stage to their final
destruction” (Minot 1901, p. 494). In his monograph The problem of age, growth, and
death, Minot stressed the field of morphogenesis with an understanding of the funda-
mental mechanisms of cell growth and development and the systematic change in
protoplasm from more elemental to highly differentiated cells and tissue, as a most
promising field for research (Minot 1908). Since that time, longitudinal or serial stud-
ies of human growth, have demonstrated relatively rapid growth during the perinatal
period, continued prepubertal growth, the rapid spurt with puberty (seen only in
humans), with continued growth for a decade or more until the mid-third decade of
life (Scammon 1927). In most mammals, when corrected with an appropriate time
scale, growth follows a smooth curve that plateaus (Brody 1945). The relative roles of
growth hormone, insulin, insulin-like growth hormones, leptin, cell cyclins, and other
hormones in hyperplasia and hypertrophy are yet to be defined.
Of course, as articulated by Horatio Hackett Newman (1875–1957), Professor of
Zoology at the University of Chicago, in regards to twins (whether monozygotic,
e.g., identical, or dizygotic, fraternal) the biologic and physiologic considerations
differ from that of a singleton infant (Newman 1917, 1923, 1940). Not only do twin
infants tend to be born prematurely and therefore relatively small, but they have
higher rates of mortality and morbidity than infants born at term (Benirschke 1961;
Guttmacher and Kohl 1958; Stoch and Smythe 1963). Some reference to the placen-
tal pathologic aspects of monochorionic twins and their consequences for fetal
growth has been given earlier. For reference, a multitude of particulars with compre-
hensive data in relation to growth are given in one of the volumes of the Biological
Handbook series published under the aegis of the Federation of American Societies
for Experimental Biology (Altman and Dittmer 1962).
One of the first to study the quantitative aspects of growth of the fetus and new-
born and the relation to nutrition and the environment, was the Scottish biologist and
classicist D’Arcy Wentworth Thompson (later Sir D’Arcy; 1860–1948) (Fig. 10.1a)
of University College, Dundee and the University of St. Andrews, Scotland.
Thompson’s 1917 masterly On growth and form departed from the contemporary
conventional consideration of anatomy and morphology, demonstrating that growth,
from embryo to fetus to infant to maturity, encompasses an orderly and progressive
change that follows mathematical principles. He presented calculations of allome-
try, i.e., the determination of the relations of two varying dimensions for various
structures from the shape of cells to the development of organs. Differences in forms
of related animals he described by relatively straightforward mathematical transfor-
mations. With his heritage in the classics and strengths in biology, Thompson held
10.1 Early Studies 185

Fig. 10.1 (a) Sir D’Arcy Wentworth Thompson (1860–1948). (b) Sir John Hammond (1889–
1964). (c) Robert Alexander McCance (1898–1993). (d) Elsie May Widdowson (second from left)
upon receipt of Commander of the Order of the British Empire, with Friends (1979)

that all learning in science constitutes a unity. In his analysis of life forms, he attempted
to reduce biologic development as being subject to the laws of physics, mechanics,
and mathematics, following varying rates and degrees along well defined develop-
mental “gradients.” A central motif is his consideration of the logarithmic spiral in
life forms. In speaking of growth, Thompson suggested a dimension to the scientific
quest, an almost transcendental value beyond our ken. He stated,
186 10 Fetal–Neonatal Growth and Metabolism

The search for differences or essential contrasts between the phenomena of … animate and
inanimate things has occupied many mens’ minds, while the search for community of prin-
ciples, or essential similitudes has been followed by few … the physical phenomenon
which meet us by the way have their manifestations of form, not less beautiful and scarce
less varied than those which move us to admiration among living things. The waves of the
sea, the little ripples on the shore, the sweeping curve of the sandy bay between its head-
lands, the outline of the hills, the shape of the clouds, all these are so many riddles of form,
so many problems of morphology, and all of them the physicist can more or less easily read
and adequately solve: solving them by reference to antecedent phenomena, in the material
system of mechanical forces to which they belong, and to which we interpret them as being
due. They have also, doubtless, their immanent teleological significance; but it is on another
plane of thought from the physicist’s [sic] that we contemplate their intrinsic harmony and
perfection, and “see that they are good”.
(Thompson 1917, p. 7)

This “other plane of thought” for Thompson was of a somewhat platonic cast, but
we need not imagine a metaphysical dimension to acknowledge that in our understand-
ing there is a component that lies outside the “material system of mechanical forces.”
He stressed that the “… problems of growth are essentially physical problems; and the
morphologist is, ipso facto, a student of physical science” (Thompson 1917, p. 8).
Strictly speaking, only two chapters of Thompson’s tome On growth… concern
growth per se. In Chapter XVII “On the Theory of Transformations, or the
Comparison of Related Forms,” he demonstrated the formation of related organic
forms, presented graphically and mapped out in accordance with Cartesian coordi-
nates (Thompson 1917). A “descriptive” work sui generis, Thompson presented no
fundamental thesis of causality between these emerging forms and the underlying
laws of physics or biology. He admitted that this work was only a first approxima-
tion, having “… little need [for a] preface, for indeed it [the entire volume] is all
preface from beginning to end” (Thompson 1917, p. v). An opponent of “vitalism,”
Thompson originally had discussed these concepts as an “… exploration of the bor-
derline of morphology and physics.” He noted that although contemporary chemistry
had not reached a science of “… mathematical mechanics, nevertheless physiology
is vastly strengthened and enlarged by making use of the chemistry … [and] physics,
of the age. Little by little it draws nearer to our conception of a true science, with
each branch of physical science which it brings into relation with itself: with every
physical law and every mathematical theorem which it learns to take into its employ”
(Thompson 1917, pp. 1–2). Thompson continued his credo, “My sole purpose is to
correlate with mathematical statement and physical law certain of the simpler out-
ward phenomena of organic growth and structure or form: while all the while regard-
ing, ex hypothesi, for the purpose of this correlation, the fabric of the organism as a
material and mechanical configuration” (Thompson 1917, p. 10). In Chapter III “The
Rate of Growth,” Thompson considered the role of varying growth rates on form, and
successive growth velocities moving through space and time.
In his 1911 presidential address to the British Association for the Advancement of
Science, “Magnalia Naturae; or the Greater Problems of Biology,” Thompson con-
sidered the “formidable complexity” of development, confessing, “… that we are
utterly ignorant of the manner in which the substance of the germ-cell can so respond
10.1 Early Studies 187

to the influence of the environment as to call forth an adaptive variation….” Thompson

continued, considering the question of whether “… something other than the physi-
cal forces animates and sustains the dust of which we are made … is rather the busi-
ness of the philosopher than the biologist.” He stressed that the structure of an object
is a “diagram of forces” (Thompson 1911, pp. 422–423). In an address “Morphology
and Mathematics” given to the Royal Society of Edinburgh, he expanded upon these
ideas stressing the value of mathematical analysis and use of Cartesian coordinates
in understanding proportion and developmental transformations (Thompson 1915).
In 1942, Thompson published a second and greatly revised (over 1,000 pages) edi-
tion of On growth and form (Thompson 1942). A scholar of the classics, in 1928
Thompson served as President of the Classical Association of England and Wales,
and in 1936 as President of the Scottish Classical Association (Thompson 1976).
With his considerable influence on the fundamental principles of scientific discovery
and thought, Thompson was knighted in 1937 (Dobell 1949; Thompson 1976).
A work noted in Chap. 7 on embryology that presents a quasi-mathematical
approach to embryonic development, and which may have played a role in
Thompson’s analysis, was Growth in length; embryological essays by Richard
Assheton (Assheton 1916). A yet earlier work devoted to growth of the human was
that of Hastings Gilford (1861–1941), a surgeon in Reading, who published The
disorders of post-natal growth and development (Gilford 1911). Previously, Gilford
had described a case of progeria, a term he coined (Gilford 1897), and later was
named “Hutchinson-Gilford progeria syndrome.” In this volume, Gilford chiefly
reviewed a number of disorders of growth and development including malignancies,
which presciently he stressed constituted a vast group of diseases, rather than a
single entity (Gilford 1911).
Another notable in establishing principles of growth, and differentiating between the
role of genetics and that of uterine environment, was John Hammond (later Sir John;
1889–1964) (Fig. 10.1b), of Cambridge University. After initially studying agriculture,
during the “Great War” as an officer in the British Expeditionary Force he became inter-
ested in animal production to optimize the nutrition of troops under his command.
Following the war, Hammond fell under the influence of Francis Hugh Adam Marshall
(1878–1948) to work on veterinary physiologic issues such as, “fertility, milk secretion,
and growth.” With limited funding, at Cambridge where he was a colleague of Barcroft,
Hammond commenced his experimental studies in rabbits, developing strains for pro-
duction of either meat or milk, and for differing fertility rates (Hammond and Marshall
1925). Early, he sought evidence for the importance of antenatal environment, and the
role of the mother in determining the size of her offspring at birth. Demonstrating this
maternal role in the rabbit, but nonetheless with the continual problem of limited fund-
ing, he collaborated with Arthur Walton (1897–1959) of the School of Agriculture.
Taking advantage of the huge size difference between breeds of horses, these investiga-
tors conducted their classic study of reciprocal crosses between the Shire and Shetland
breeds. Hammond and Walton postulated that any difference in size between the off-
spring of the reciprocal crosses “would therefore be due not to chromosomal differences
but to differences in the environment brought about by difference in the size of the
188 10 Fetal–Neonatal Growth and Metabolism

mother. In other words we would have a controlled experiment in which “mother-size”

was the only or predominating variable” (Walton and Hammond 1938, p. 312).
Despite opposition from colleagues who thought the experiment cruel and/or unethi-
cal, these workers used the newly developed technique of artificial insemination, which
Walton had learned on a visit to Russia (Walton 1936), to impregnate the mares with
semen from stallions from the opposite breed. Strikingly, at term the three Shetland
mares bore foals weighing ~18 ± 2 kg, as compared to the pure Shetland foals of
~20 ± 2 kg. In contrast, the Shire dams (weighing several times that of the Shetland
mares) bore foals weighing 49 ± 2 kg, compared to purebred Shire foals of ~71 ± 5 kg
(Walton and Hammond 1938). To the amazement of attendees of a Cambridge meeting
of the British Society for Experimental Biology, Hammond displayed these dams and
their offspring to establish his thesis. “The contrast in weight and size [of the foals] was
so enormous that it was difficult for the assembled scientists to believe the evidence of
their eyes” (Slater and Edwards 1965, p. 104). Following weaning, the genetic differ-
ences in these foals became apparent, when on similar diets, the crosses from the Shire
mares grew less rapidly than purebred Shire foals, while those from the Shetland dams
grew more rapidly than purebred Shetlands. At about 18 months of age the growth rates
of the foals became constant; nonetheless, the differences between reciprocal crosses
persisted into adulthood (Walton and Hammond 1938).
Hammond later followed this equine experiment, with similar studies in cattle, sum-
marizing this work in major reviews (Hammond 1940; Hammond and Walton 1938).
Although these results suggest that fetal growth is regulated entirely by uterine con-
straint, other maternal factors have been shown to play a major role. For instance, studies
of mice of different strains suggest that intrauterine constraint is operative principally in
late gestation (Aitken et al. 1977). The inverse correlation between birthweight and litter
size in rodents and other mammals, and the late-gestation slowing of growth rate in
human twin pregnancy support this view. For many of his studies on growth and the
development of bone, muscle, and fat, Hammond often attended Stock Shows in
surrounding communities (Slater and Edwards 1965). Importantly for animal husbandry
throughout the world, Hammond’s work contributed greatly to optimize the production
of cattle (for beef and milk), sheep, and swine (Hammond 1940; Marshall and Hammond
1946). In the UK, Walton and Hamilton’s introduction, to and advocacy of the technique
of artificial insemination contributed greatly to the improvement of animal breeding.
In 1949, Hammond was appointed a Commander of the Order of the British Empire,
and in 1960 he was knighted (Sanders 1965; Slater and Edwards 1965). The following
year (1961), Hammond co-chaired the Ciba Foundation Symposium Somatic Stability
in the Newly Born (see below) (Hammond 1961a, b).

10.2 Robert A. McCance, Elsie May Widdowson, and

Continued Studies of Growth and Metabolism

Consideration of neonatal growth and metabolism also must reference Robert A.

McCance (Fig. 10.1c) and his long-time associate Elsie May Widdowson (1906–
2000) (Fig. 10.1d). Both of these workers’ contributions to the chemical composition
10.2 Robert A. McCance, Elsie May Widdowson, and Continued Studies of Growth… 189

of foods and nutrition, changed the understanding of metabolic energy balance in

newborn infants and children. Following his service as a pilot with the Royal Naval
Air Service during World War I, McCance obtained his Cambridge doctorate in bio-
chemistry under Sir Frederick Gowland Hopkins. He also studied physiology under
Joseph Barcroft, “who became one of his heroes.” Because of his interest in clinical
chemistry, McCance then enrolled in King’s College Hospital, London to complete
his medical education (MB, 1927; MD, 1929). Although acknowledged widely for
his contributions to infant nutrition, McCance investigated a variety of problems in
metabolism, the composition of foods, and that of body tissues, and the body’s
responses to cold and heat. His early studies on the chemical composition of raw and
cooked foods, performed under the aegis of a small subvention from the Medical
Research Council, obtained by his mentor and early specialist in diabetes Robert
Daniel Lawrence (1892–1968), lead to a special MRC report The carbohydrate con-
tent of foods (McCance and Lawrence 1929). This was followed by three other such
special MRC reports on various types of foods (McCance and Shipp 1933; McCance
and Widdowson 1940; McCance et al. 1936). During these years, McCance also
involved himself in studies of mineral metabolism and salt balance (McCance 1936).
Because of the influence of the newly appointed (1935) Regius Professor of
Physic, John Alfred Ryle (1889–1950), in 1938 McCance was asked to return to
Cambridge as a Reader in Medicine. Later (1945), the Medical Research Council
created a personal chair for McCance, and he chose the title Professor of
Experimental Medicine. This unit was the first such in the UK. As at mid-century,
Ryle played a critical role in the development of clinical research in Great Britain,
it may be of value to consider in brief his contributions. Previously at Guy’s Hospital,
London, Ryle came to believe strongly that clinical science in medicine constituted
an important aspect of academics and the profession (Ryle 1930). In part, this con-
cept and commitment was due to the influence of Sir Thomas Lewis of University
College Hospital. As noted earlier, Lewis was a UK pioneer on the role of scientific
investigation to the advancement of medicine (Lewis 1930). In a 1931 address to the
Cambridge University Medical Society, “The physician as naturalist,” Ryle sum-
marized his views (Ryle 1931). In opening his address he quoted Francis Bacon’s
Advancement of Learning, “Only there is one thing remaining, which is of more
consequence than all the rest: namely, a true and active Natural Philosophy for the
Science of Medicine to be built upon” (Ryle 1931, p. 278). Upon moving to
Cambridge, and assuming his Regius Professorship, in his inaugural lecture “The
aims and methods of medical science” Ryle elaborated on his views of the physician-
scientist. He observed, “The aims of medical science … are to increase and perfect
our knowledge (with a view to its control) of disease in man, and equally our knowl-
edge of man in disease, by every legitimate means of science and art at our disposal”
(Ryle 1935, p. 8). Stressing the role of the University in this regard, Ryle called for
“… a renaissance in Medicine, which will be marked by an eagerness on the part of
the younger men … to turn more frequently to the study of problems at the bed-side
and with a greater care and accuracy than they have ever before been studied … the
ward, with its associate out-patient clinic and laboratories, must become once more
both the starting and the rallying point of many researches” (Ryle 1935, pp. 40–43).
To implement his ideals, Ryle sought to establish at Cambridge’s Addenbrooke
190 10 Fetal–Neonatal Growth and Metabolism

Hospital a strong program of clinical-translational research (Weatherall 2000). In

attracting him to this newly created post, Ryle held that McCance represented a new
variety of physician investigator who specialized in that most fruitful branch of sci-
ence—biochemistry in its application to medicine.
In the mid-1930s, a chance observation by one of McCance’s former house phy-
sicians, Winifred Ferguson Young (1909–1969), who had worked with him on
experimental salt deficiency in adults, changed the course of their lives. Young had
moved to the Children’s Hospital in Birmingham to work under Sir Leonard Gregory
Parsons (1879–1950), a UK leader in the development of pediatrics as a medical
specialty. An advocate of “antenatal paediatrics” (Neale 1956; Parsons 1946),
Parsons had called attention to rickets (Vitamin D deficiency) (Parsons 1928) and
scurvy (Vitamin C deficiency) (Parsons 1933) in infants. In the course of testing the
urine of newborns for sugar and albumin, Young also had measured the extent to
which these infants excreted “proper amounts” of chloride. To her astonishment,
she discovered none of this anion, raising the question of whether these newborns
were salt deficient. After reporting this to McCance, they decided to commence
renal function studies in newborn infants. Later, McCance recorded that,
… we decided therefore, albeit with some trepidation, to make as satisfactory an investiga-
tion of renal function of newborn infants as we felt would be ethically correct. We did not
feel justified in catheterising normal newborn infants and making multiple venous punc-
tures for the injection of solutions of inulin and the collection of timed specimens of urine
and blood, but someone … suggested that we should use infants born with inoperable
meningomyeloceles for such investigations. After considering very carefully … we decided
to make the studies … and we did the infants no harm by doing so.
(McCance 1978, p. 2)

With a battery of tests (glomerular filtration rate, inulin clearance, and others),
McCance and Young discovered that, compared to the adult, the newborn kidney in
many respects was inefficient, forming hypotonic urine (McCance and Young 1941).
When we came to consider our results it was clear that the kidneys of the newborn infant
had very low clearances of urea, chloride, and sodium by adult standards, and also very low
powers of concentration. The serum potassiums were on the whole higher than those of
adults, occasionally twice as high, and the clearances low. In short, the kidney of the new-
born infant was revealed to be a relatively ineffective organ. Yet it was apparently able to
maintain the internal environment in a healthy state.
(McCance 1978, p. 2)

This phenomenon was even more pronounced in the premature newborn (Young
et al. 1941). McCance extended these studies to newborn laboratory animals: rats,
puppies, and piglets (McCance 1948). He demonstrated in humans and other spe-
cies that the renal system does not acquire the capacity to regulate these functions
(fluid, electrolyte, and acid–base balance) until the newborn period and suggested
that “… mother’s milk was such a perfectly constituted food for the newborn, and
the rate of growth at that time was so great … that for a period after birth the kidney
had little to do. Subsequent work revealed [this to be] correct” (McCance 1978, p. 3).
Later, Young was appointed research clinician to London’s Queen Elizabeth
Hospital for Children (1948), and was a driving force in founding (1962) the
10.2 Robert A. McCance, Elsie May Widdowson, and Continued Studies of Growth… 191

Research Appeal Trust (Anonymous 1969). Findings by these workers led to the
appreciation of growth during infancy in maintaining stability of the milieu interior,
as defined by Claude Bernard (Bernard 1865).
When fed on mother’s milk, the newborn’s rapid growth required so much of the
ingested nutrients, with the nitrogen being incorporated into growing tissue, that the
infant “… could almost do without kidneys at all” (McCance 1948; Widdowson
1993, p. 385). During the following decade, understanding of renal function in the
newborn infant made great progress, including comparisons and contrasts of humans
with other mammals, and aspects of the relation of renal function to body growth and
metabolism (Alexander et al. 1958; Smith 1959). As an example, Gertrude Falk
(1925–2008), working with Adolph at the University of Rochester, reported studies
on mechanisms of postnatal renal development. In the rat, Falk examined renal
responses to water excess, water deprivation, hypertonic solutions, and the effect of
posterior pituitary and adrenal hormones, in an attempt to determine the basis of
impaired water excretion, reduced glomerular filtration rate, and inability to concen-
trate urine in the newborn (Falk 1955). With the support of a Guggenheim Fellowship,
in 1961 Falk moved to University College, London, where she remained to explore
the mysteries of photoreceptor cells in the retina (Anonymous 2008).
As is well known, the onset of World War II necessitated food rationing. As a
consequence, the threat of undernutrition was appreciated as being a potentially
important clinical problem. With their background in nutrition (see Widdowson and
Shackleton 1936) McCance and Widdowson, members of the Medical Research
Council (MRC) staff, prepared their classic monograph The chemical composition
of foods (McCance and Widdowson 1940). At the end of the War, and aware of the
impending critical food shortage in Germany, McCance persuaded Sir Edward
Mellanby, Secretary of the MRC, of the need for a team of experts to study the
effects of undernutrition on metabolism and well being on the continent. Following
a preliminary survey, the small town of Wuppertal, Germany, an area in which adult
rations were only about 1,000 kcal·day−1, and in which “hunger edema” was preva-
lent, was selected as the site for these studies. The series of studies on this popula-
tion were published as a MRC Special Report, Studies of undernutrition, Wuppertal,
1946–1949 (McCance and Widdowson 1951). In these reports, McCance focused
his efforts chiefly on malnutrition in the adult population, while Widdowson fol-
lowed these effects in children (see below and Widdowson 1995). One study of this
series examined the effects of undernutrition and size at birth, and the yield of
maternal breast milk (Dean 1951).
These studies in Germany were followed by a series of experiments on nutrition
and metabolism in the newborn. Upon understanding that in the newborn infant,
growth, rather than the kidneys, played a critical role in maintaining homeostasis, as
defined by Walter B. Cannon (Cannon 1932), McCance summarized these studies
on aspects of newborn metabolism and its regulation in his 1959 Sir Leonard
Parsons Lectures at Birmingham, in tribute to the individual who had done so much
to develop the field of infant nutrition (McCance 1959b). He also reviewed this
work in his 1962 Lumleian Lecture to the Royal College of Physicians, “Food,
192 10 Fetal–Neonatal Growth and Metabolism

growth, and time” (McCance 1962). In addition, McCance reviewed his and others’
studies on thermal stability in the newborn (McCance 1959a). As an aside, McCance
resided in Bartlow, a village about 20 km from Cambridge, from which he daily
cycled to and from his office. Widdowson has recorded that “… he used his cycling
time to think up new ideas for research or to solve problems arising from those
already underway” (Widdowson 1993, p. 386). In a 1980 tribute to McCance,
Widdowson recorded that in the 1950s and 1960s, McCance, “… paid many visits
to Oxford to learn all he could about the work of Geoffrey Dawes and his group
were doing, and to London to see Kenneth Cross and [others] … He always came
back full of enthusiasm about the discoveries these people were making, and his
lectures covered their pioneering work as well as his own” (Widdowson 1980, p. 3).
Several years later, McCance updated this synthesis in his contribution
“Characteristics of the newly born” for the 1961 Ciba Foundation Symposium on
Somatic Stability in the Newly Born, in which Dawes participated. In this review,
McCance stressed that despite “instability” of many metabolic functions in the new-
born, its “tolerance” and plasticity is considerable (McCance 1961). In two further
recapitulations a decade following his “retirement” in 1966, McCance addressed the
issue of “Critical periods of growth,” and the thesis that, for the undernourished
newborn, its ability or non ability for “catch up” growth, was a function of the tem-
poral relation to the period of under-nutrition to the time of maturation of the hypo-
thalamic food satiety centers (McCance 1976, 1977). In an effort to study further
several aspects of fetal metabolism, McCance experimented with development of an
artificial placenta, which he used on piglets and several non viable human fetuses
(Lawn and McCance 1962). Several decades later, in recalling his interactions with
McCance, Dawes stated, “Perinatal physiology owes a great debt to the pioneer
work of Professor McCance and his distinguished colleagues on renal function and
nutrition … My own interests were in an area somewhat different to that which Mac
had already established. He had set us the excellent example of combining basic and
applied research without letting one dilute the other.” Dawes also praised McCance’s
“… initiative… and interdisciplinary cooperation on a friendly and informed intel-
lectual scale” (Dawes 1980, p. 4).
Having joined McCance in Cambridge at the time of his 1938 move, Elsie May
Widdowson continued their collaboration on renal function, metabolism, and ther-
mal regulation of the newborn. As noted, following World War II, this was inter-
rupted by a 3 year “sabbatical” (1946–1949) working in Wuppertal on nutrition
with emphasis on that of children. With several orphanages nearby, she determined
the optimal constituents for a loaf of bread for the growth of children that were
undernourished (Widdowson and McCance 1954). In these studies, Widdowson ser-
endipitously discovered the importance to growth and development of emotional
contentment and mental well-being, despite adequate nutrition per se (Widdowson
1951). She wrote, “Tender loving care of children and careful handling of animals
may make all the difference to the successful outcome of a carefully planned experi-
ment.” In reference to this conclusion, one of her associates commented, “love must
be the best diet” (Ashwell 2002, p. 495).
10.2 Robert A. McCance, Elsie May Widdowson, and Continued Studies of Growth… 193

Following her return to Cambridge in 1949, Widdowson commenced a study in

which she compared body composition of human fetuses and stillborn infants, with
that of an older child and several adults (Widdowson and Dickerson 1960). She
extended this study, examining body fat in several species, showing that in compari-
son to the newborn of many species with 1–2 % body fat, at birth the human infant
has ~16 % body fat. These studies also demonstrated some general principles, such
as the long-term impact of early nutrition on development (Widdowson 1963), as
well as important species differences relating to maturity. To compare chemical
development in the various tissues, Widdowson noted that one must calculate the
constituents per unit of fat-free body mass. In other studies, with a herd of pigs
McCance raised at his home in Cambridgeshire, she followed up her post-war
Germany studies on the relation of severe under-nutrition to subsequent reproduc-
tive function in the adult (Widdowson 1974). In the 1961 Ciba Foundation
Symposium Somatic Stability in the Newly Born, Widdowson summarized many
aspects of newborn metabolism, with comparison of the human to that of the piglet,
calf, and kitten (Widdowson 1961). Almost two decades later, in a manner reminis-
cent of Minot (Minot 1891), McCance and Widdowson collated data from a number
of reports on rates of growth of 17 species and their length of gestation. Their graph-
ical representation suggested that these growth profiles could be classified into three
groups: those that grow at a quite rapid rate (mouse, rat, rabbit, blue whale), those
species that grow at a more modest rate (cat, dog, guinea pig, goat, pig, sheep, por-
poise, hippopotamus, horse), and those that grew at a still slower rate (macaque,
man, ox, elephant) (McCance and Widdowson 1978). In addition, McCance and
Widdowson graphically depicted the species differences in percentage of solids ver-
sus water in lean body tissues. They compared the human fetus during gestation,
with that for nine other species at the time of birth. Not only do these other species
grow in size more rapidly than the human, but the percentage of body solids
increases much more rapidly. In considering the biochemistry of growth, these
workers stressed the challenge of understanding the mechanisms by which the
various cell types of different species change in a relatively consistent manner
(see also McCance and Widdowson 1974; McCance et al. 1978). They concluded
with the observation,
The search for an animal model to further our knowledge of man has become fashionable,
and the phrase itself has become a modern cliché. It is safe to say that the search will make
little difference to the work being done on animals, which is frequently undertaken for its
own sake. It is interesting, however, to speculate how much would be known about human
growth requirements and the physiology of growth had animals not been studied. It is
indeed the value of a comparative approach that we have tried to show, for it is the one way
which enables one to realize the importance of species differences and hence of picking the
appropriate animal with which to solve the problem at hand or perhaps initiate some wide-
spread biological principle. If those interested only in human nutrition want an animal
model, they are crying for the moon unless they have the patience and the ability to find it for
the particular purpose they have in mind.
(McCance and Widdowson 1978, pp. 161–162)

In 1968 at the time of McCance’s retirement, Widdowson became head of the

Infant Nutrition Research Division of the MRC’s Dunn Nutrition Laboratory. Here,
194 10 Fetal–Neonatal Growth and Metabolism

she compared the composition of infant milk formula from several European coun-
tries. With the formula in Holland, in which the cow’s milk fat was replaced with
maize oil consisting of 60 % fatty acids in the form of polyunsaturated linoleic acid
(as compared to 8 % in human breast milk and 1 % in the cow), she demonstrated
significant effects on infant body fat (Widdowson et al. 1975). To ascertain the dif-
ference this markedly elevated level of unsaturated fatty acid made on the composi-
tion of various tissues, she also studied the effect of altered milk formula in newborn
guinea pigs (which have ~10 % body fat at birth). In this latter study she demon-
strated major compositional differences in several organs, including that of myelin
in the brain (Pavey and Widdowson 1980). She also performed comparative studies
of nutrition and neonatal growth in rats, guinea pigs, and pigs (Widdowson 1974).
Following her 1973 move to Addenbrooke Hospital’s renamed Department of
Investigative Medicine (the successor to McCance’s Department of Experimental
Medicine, because several hospital authorities chaffed at the word “Experimental”),
she collaborated on a study of infant milk composition and the composition of tis-
sues in two species of Labrador Seals (Oftedal et al. 1989). Widdowson was elected
to the presidency of the British Neonatal Society (1978–1979) and the British
Nutrition Foundation (1986–1987). In 1979, Queen Elizabeth II (Elizabeth
Alexandria Mary) awarded her Commander of the Order of the British Empire, and
in 1993, Companion of Honour (1993) (Ashwell 2002).

10.3 Neonatal Birthweights and the Small for Gestational

Age Infant

In terms of fetal growth and development, perhaps surprisingly, reasonably correct

birthweights of normal newborn infants were not determined until the mid-
eighteenth century. Thomas E. Cone, Jr. (1915–1998) has presented a rather fasci-
nating account of the vicissitudes in measurement of what one would regard as this
rather straightforward variable (Cone 1961). As has been documented in many stud-
ies, prior to the mid-twentieth century the outlook for newborn infants, regardless of
size and gestational age, was fraught with hazards, particularly for those infants not
nursed by their mothers. A significant factor in determining their fate was how they
were fed. It was in late-nineteenth and early twentieth centuries that weighing of the
newborn became a relatively common practice, and contributed to defining an index
of viability. Nonetheless, at this time some recognized that “… tiny-puny” infants
could possess great vitality, and that gestational age was as important as birth weight
per se (Budin 1907). Weighing also was used to determine milk intake, and by the
association of nutrition and body weight to health, was used as a quantitative mea-
sure of normality of growth and development (Weaver 2010).
Not until the mid-twentieth century did the concept arise that some small neo-
nates gave evidence of growth failure, rather than being born prematurely. To that
time, all infants who weighed <2,500 g were classified as “premature” (for instance,
“Expert Group on Pre-Maturity” of the World Health Organization defined
10.3 Neonatal Birthweights and the Small for Gestational Age Infant 195

Fig. 10.2 (a) Joseph Dancis (1916–2010). (b) Lula O. Lubchenco (1915–2001)

premature on the basis of birth weight, e.g., <2,500 g, alone; World Health
Organization 1950). Thus, the idea of a fetus being small for gestational age (SGA)
and failing to reach its full potential was pioneering. In 1947 from Los Angeles “…
with much trepidation,” a report of SGA newborns was presented on 69 undernour-
ished infants (of 6,641 total over 44 months) at term (McBurney 1947). These infant
weights ranged from ~1.5 to 2.5 kg, and the placentas tended to be smaller than
normal. By California State Board of Health statistical requirements, the infants
were “premature” despite their being born at or near full-term (McBurney 1947). In
another series shortly thereafter, of 20 such infants, the small-for-dates infants were
diagnosed in utero by both serial measurements of pubic symphysis to uterine fun-
dus height, as well as weight at the time of birth. Excluding stillborns and one
mongoloid infant, the weight of the 12 surviving infants was 1702 ± 135 g (Rumbolz
and McGoogan 1953). Since that time, it has become recognized that a number of
such low birth weight infants are a consequence of decreased rate of intrauterine
growth, e.g., shades of Minot, rather than their being delivered prior to term. The
relevance of this concept was affirmed by subsequent studies that demonstrated cor-
relations of stillbirth and fetal asphyxia to restricted growth. To account for smaller
than normal size and weight, the terms “small for gestational age,” “intrauterine
growth restriction” (IUGR; initially “retardation”; Gruenwald et al. 1967; Warkany
et al. 1961), and “fetal growth restriction” (FGR) were introduced to describe
these infants.
In an historic perspective, the late Joseph Dancis (1916–2010) (Fig. 10.2a), of
New York University and the Bellevue Hospital, recalled that in regards to normal
patterns of newborn growth it was when he was a senior resident that his chief of
Pediatrics, Luther Emmett Holt Jr. (1895–1974), pointed out the lack of standard
weight curves for premature infants. This made it difficult to judge the progress of
a given infant following birth (Dancis 1983). Dancis enlisted a fellow resident to
tabulate the weight gains for their first 50 days of life of a series of 100 infants that
196 10 Fetal–Neonatal Growth and Metabolism

weighed from 1,000 to 2,500 g at the time of birth. On analyzing what appeared a
“tangled mass of curves,” Dr. Holt “… sketched in over them, at 250-gram intervals,
simple straight lines seeking to reproduce the summation of the slopes.” Following
some corrections, with the early weight losses, “… the rough outline of the premie
weight grid emerged” (Dancis 1983, p. 3; Dancis et al. 1948). Here, Dancis admit-
ted the unusual nature of their report. There was no section on methods (including
the population surveyed, criteria for inclusion or exclusion), no careful analysis of
results, no regression lines, or statistics, and no “… extensive and penetrating dis-
cussion” (Dancis 1983, p. 2). Of note, the shape of the grid demonstrates that less
mature preemies reach their weight nadir later than those that are more mature, and
their rate of weight gain is slower so that they require more time to regain their
birthweight. These observations on the significant decrease in weight during the
first days to week of life confirmed an earlier study of the weight changes of almost
3,000 newborns, which separated males and females and white and blacks (Dunham
et al. 1939).
A decade and a half later, Lula O. Lubchenco (1915–2001) (Fig. 10.2b) and col-
leagues at the University of Colorado first described the relation of birthweight to
gestational age (Lubchenco et al. 1963). Although their study was conducted at
moderately high altitude (Denver, CO, 1,609 m, 5,280 ft), it set a new standard for
evaluation of the newborn, and the “Lulagram” developmental growth chart became
used world-wide. For infants whose growth patterns lie outside normal develop-
mental profiles, the terms small-, appropriate-, and large- for gestational age (SGA,
AGA, and LGA) were introduced on the basis of weight, length, head circumfer-
ence, and weight–length ratio (ponderal index) (Battaglia and Lubchenco 1967;
Lubchenco 1970; Lubchenco et al. 1966, 1972). Although the term “low-birth
weight” was introduced in the early sixties to replace the word “premature” for
infants under 2,500 g at birth, its acceptance was markedly facilitated by Lubchenco’s
popularization of matching birthweight with gestation. Too long had the designa-
tion for term and premature been based on birth weight above and below 2,500 g
without awareness of two distinct populations for each weight group. A study by the
University of California, Berkeley biostatistician Jacob Yerushalmy (1904–1973)
and coworkers showed that there were as many term as preterm infants born weigh-
ing under 2,500 g in the USA and surprisingly more preterm infants weighing above
than below that figure (Yerushalmy et al. 1965).
In her monograph The high-risk infant, Lubchenco summarized standards of
intrauterine growth from the 24th to the 42nd week of gestation. She emphasized
the importance of the use of gestational age, along with birthweight, as a dimension
to understanding not only prenatal and perinatal risk factors, but also in the consid-
eration of long-term outcome (Lubchenco 1976). Her work became a classic. The
studies of Lubchenco and others helped to replace the pediatric concept of “failure
to thrive” with that of the extent to which the yet to be born infant thrives.
Subsequently, several investigators have reported birthweight-gestational age data
for infants born at sea level among different groups (Altman and Coles 1980; Ballard
et al. 1979; Brenner et al. 1976; Dunn and Wharton 1985; Gardosi et al. 1992; Usher
1970; Usher and McLean 1969; Usher et al. 1966). The introduction of diagnostic
10.3 Neonatal Birthweights and the Small for Gestational Age Infant 197

ultrasound, with measurements of both head and abdominal circumference and

femur lengths has helped to revolutionize the determination of fetal body size in
utero. Although continuous throughout pregnancy, fetal growth follows a biphasic
curve, with the period ~32 weeks being most rapid for acceleration in mass (weight)
gain, and ~18 weeks for the peak rate of increase in body length (Tanner 1978;
Villar and Belizan 1982).
Although many instances of IUGR have been attributed to “placental insuffi-
ciency” (Gruenwald 1963, 1970), the term has caused confusion in the literature, and
been defined in various ways. A skeptic, Nicholas Salem Assali (1916–2004) of the
University of California Los Angeles, stated the term to be,
… an umbrella to cover our ignorance of the etiology and pathogenesis of chronic
uteroplacental-fetal disturbances; … a waste basket to dump a variety of disorders interfer-
ing with maternal supply of nutrients to the fetus or with fetal metabolism or with disorders
related to abnormal placental functions … in my opinion, there is no adequate physiological
method to test placental sufficiency or insufficiency.
(Assali et al. 1975, p. 88)

Nonetheless, others dispute this view, noting not only altered function of the
placenta, but many circulatory and metabolic changes of the fetus (Battaglia 2011).
The ability to distinguish between an infant born “too soon” (preterm), versus that
which is small for gestational age (whether due to nutritional deficiency as noted
above, or the fact that the parents are small), has important biological implications,
including their care of these infants clinically, as their rates of morbidity and mortal-
ity vary considerably (Abramowicz and Kass 1966; Battaglia 2011; Battaglia and
Simmons 1978; Low et al. 1972; see below).
Also at mid-century, a number of other concerns became evident. One was that
of neurological development, and the use of neurological testing to determine ges-
tational age. Initially in these studies the examiner attempted to characterize the
newborn’s reflexes and tone (Saint-Anne Dargassies 1955; Thomas and Saint-Anne
Dargassies 1952). Subsequently, these were quantified, in part, for seven groups
from 28 to 40 weeks gestational age (Amiel-Tison 1968; Amiel-Tison and Grenier
1980). Soon these criteria were refined further (Dubowitz et al. 1970; Fitzhardinge
and Steven 1972; Robinson 1966). Another was the question of the optimal nutri-
ents to feed infants, particularly those that were premature. Nutritional balance
studies of Harry H. Gordon (1906–1988) and Samuel Zachary Levine (1895–1970),
of Cornell University Medical Center, in New York City were the first to establish
an evidence-based scientific basis for infant feeding (Gordon and Levine 1944).
Soon it became evident that mother’s milk, with its rich content of carbohydrates,
proteins including immunoglobulins, calcium, and other constituents, is the most
desirable food for premature and term infants. In the late 1970s, Frank Tardrew
Falkner (1918–2003) of the Fels Research Institute, Wright State University, Ohio,
and James Mourilyan Tanner (1920–2010) of the Institute of Child Health,
University of London, edited a three volume arbeit on human growth. In 21 chap-
ters, Volume 1, Principles and Prenatal Growth, addressed aspects of developmen-
tal biology, the mechanisms of regulation of growth, biometrical methods of
198 10 Fetal–Neonatal Growth and Metabolism

interpreting human growth data, the relation of genetics to prenatal and postnatal
growth, and the process of maturation (Falkner and Tanner 1978a). Volume 2,
Postnatal Growth, in 19 chapters considered methods of auxological anthropology,
growth of the various body tissues and organs, and problems of growth of the low
weight infant (Falkner and Tanner 1978b). The 17 chapters of Volume 3,
Neurobiology and Nutrition focused on neurobiological aspects of growth, growth
of the brain and nervous system, and the overall role of nutrition in growth and
maturation (Falkner and Tanner 1979). The final chapter presents a history of scien-
tific growth studies, from that of Georges Louis Leclerc Comte Buffon (1707–1788)
in the eighteenth century, to D’Arcy Thompson and others in the early twentieth
century (Tanner 1979). In addition to normal standards for intrauterine growth
(Tanner 1970), Tanner is also widely regarded for his studies of children in the
Harpenden orphanage, north of London, and documenting the series of steps that
define physical maturation, growth pattern, and their variations, the “Tanner stages”
or “Tanner scale” (Tanner 1978, 1981, 1990).
In an attempt to expand the recognized number of atypical fetal growth patterns,
to provide anthropomorphic data (crown-heel lengths, ponderal index, weight–
height ratios, and others) on newborn infants who were free from all known growth-
limiting influences in utero, and to use newborn body measurements collected by a
single individual to construct standards of presumed normal fetal growth, in 1973 a
study of fetal growth in all infants (primarily Caucasian) born at the University of
Kansas Medical Center commenced (Miller and Merritt 1979). This fetal growth
research program, conducted on about 6,000 pregnancies over a 5 year period, led
to the identification of a number of factors leading to fetal growth restriction and/or
associated with premature birth. These included outcomes for teenage mothers,
those mothers over the age of 35, those who smoked, used addicting drugs, or lacked
prenatal care, and numerous other variables. In addition to providing growth stan-
dards, the investigators stressed the need for studies to determine the extent and
degree to which postnatal growth is a continuum of different patterns of prenatal
growth (Miller and Merritt 1979).
In 1988, Forrester Cockburn of the Royal Hospital for Sick Children, Glasgow,
edited a volume on Fetal and neonatal growth. Exploring early and critical phases
of human development, a dozen essayists considered what was known about the
role of genetics, growth factors, enzymes, hormones, and other antenatal and post-
natal aspects in growth and its developmental regulation (Cockburn 1988). Another
volume, Fetal growth and development edited by Richard Harding of Monash
University, Victoria, Australia and Alan D. Bocking of the University of Western
Ontario, Canada, in 12 chapters considers a number of aspects of this topic for dif-
ferent physiological systems and their relevance (Harding and Bocking 2001).
During the past several decades a number of other investigators have contributed to
studies on the role of both placental and fetal hormones and other factors that influ-
ence growth and metabolism of the fetus and newborn infant (for instance see
Fowden 1989; Fowden et al. 1996, 1998; Robinson 1977; Robinson et al. 2000;
Ward et al. 2004; Winick 1972). Because normal fetal growth is such a critical com-
ponent of a healthy pregnancy, in clinical obstetrics considerable effort has been
10.4 Metabolic Rate 199

dedicated to developing appropriate references and standards for its evaluation

(Alexander et al. 1996; Gruenwald 1966; Hoffman et al. 1974; Kramer 1987;
Williams 1975; Zhang et al. 2010).

10.4 Metabolic Rate

An additional consideration in relation to that of growth of the fetus and newborn is

that of energy expenditure and metabolic rate, these being functions of many factors
including the endocrine and nervous systems. In his Foetal and neonatal physiology
…, Dawes stressed the importance of the larger body surface area to weight in the
newborn human infant and that of other mammals, compared to the adult, in terms
of regulating their body temperature, and their rate of O2 consumption and basal
metabolic rate under varying conditions (see Dawes 1968, pp. 191 ff). For almost a
century, it has been assumed that the basal metabolic rate of an organism increases
as a function of body mass. In 1916, the Nobel prize winning physiologist August
Krogh, of the University of Copenhagen, suggested that the relation of metabolic
rate to body mass is described best by a power function. That is, rather than meta-
bolic rate being proportional to mass per se, it is a function of mass raised to some
power (Krogh 1916). In addition to proposing a power law for the relation of meta-
bolic rate to body mass, Krogh suggested that for endothermic organisms (mam-
mals and birds) the value of “p” equals 2/3, similar to the law of metabolic rate
being proportional to body surface area, as proposed earlier by Max Rubner (1854–
1932) (Rubner 1902). When the power function “p” equals unity, this relationship
is a straight line, and metabolic rate is said to scale isometrically (in proportion) to
mass. When the power function does not equal one, the relationship is curvilinear,
and metabolic rate is said to scale allometrically (in divergence or by other).
In the early 1930s, Max Kleiber (1893–1976), of the University of California,
Davis, (Kleiber 1932), and independently Samuel Brody (1890–1956), of the
University of Missouri (Brody et al. 1934), reported that across a wide range of
mammalian species, metabolic rate scales are a nonlinear function of body mass.
Kleiber’s “mouse to elephant” curves for metabolic rate suggested the value of the
scaling parameter “p” to equal 0.75. This power scaling of metabolic rate, “The Fire
of Life” (Kleiber 1961), to body mass became known as Kleiber’s Law, and has
been extended to a wide range of organisms (Hemmingsen 1960). Since mid-
twentieth century, this line of investigation has spawned a number of studies, with
investigators seeking to determine with accuracy and to explain this apparently
universal exponent and its importance (Bartels 1982; Feldman and McMahon
1983). In fact, the debate has included those who reject the concept of a single
power value to describe this relationship, stating that the value varies with environ-
ment, taxonomy, body temperature, and other factors (Dodds et al. 2001; McNab
2008; Schmidt-Nielsen 1984; White 2011; White and Seymour 2003). Recent
reports have suggested that the standard power equation may not be appropriate to
describe the relation of basal metabolic rate to body mass, and that, in fact, the value
200 10 Fetal–Neonatal Growth and Metabolism

of “p” increases with body size, e.g., the metabolic rate increases more rapidly with
mass for large animals, than for those that are small. In addition, deviations from the
exponent 0.75, which some have suggested fits a “fractal distribution network
model” based on geometry of vascular and other nutrient supply networks (West
et al. 1997), are real, as originally suggested by Krogh (Kolokotrones et al. 2010).
As noted earlier, this issue has been of great interest to fetal–neonatal physiologists,
and the question of the extent to which metabolic rate scales allometrically and its
influence on life history remain (McNab 2012).

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Chapter 11
Epigenetics and the Fetal Origins of Adult
Health and Disease

11.1 Overview

Growth and development of the embryo and fetus, once the interest of only a minor-
ity of clinicians and public health officials, currently commands the attention of all
concerned with the prevalence of a wide array of medical disorders in the adult.
These include: diabetes and related metabolic syndrome, coronary artery disease,
hypertension, schizophrenia and other neuropsychiatric diseases, as well as cancer
and other conditions. As knowledge of human development has increased, evidence
has amassed that the foundations for much of our life as adults are established in our
mother’s womb prior to birth. During the past several decades both a number of
epidemiologic studies in humans and mechanistic-based experiments in laboratory
animals, have given rise to the hypothesis of the “Developmental Origins of Health
and Disease” (DOHaD) (Barker et al. 1993; Gluckman et al. 2008). Although much
of the evidence is compelling, nonetheless controversy exists as to the basis for
many of the associations drawn (Ben-Shlomo and Kuh 2002; Joseph and Kramer
1996; Kramer and Joseph 1996). Of particular relevance in this regard is nutrition.
Commonly, we think of famine as a topic of the distant past or of malnutrition as
being of limited scope (Delisle 2008). However, with the ever increasing population
on the planet, limited resources, rise in commodity prices, and the role of politics in
human well-being, the issue of proper nutrition or the lack thereof is a world-wide
problem, and its relation to health and disease is of considerable relevance to bio-
medical scientists and members of the healing profession.
In the Western world, despite remarkable advances in the biological sciences and
other areas of life, systemic metabolic and cardiovascular disease, as well as cogni-
tive and neuropsychiatric disturbances, are far too common and represent a virtual
pandemic of morbidity and mortality. With increasing human lifespan, the number
of individuals who experience these disorders is escalating. Although associated
with a number of risk factors, as yet unrecognized elements must be considered in
the genesis of their pathology. An expanding body of evidence has highlighted the
role of environmental factors that interact with our genetic code by epigenetic

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 207
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_11, © American Physiological Society 2013
208 11 Epigenetics and the Fetal Origins of Adult Health and Disease

Fig. 11.1 (a) and (b) Images from the Dutch Hunger Winter. (c) Conrad Hal Waddington (1905–
1975). (d) David J.P. Barker (1938–2013)

mechanisms to modulate gene expression of individual cells. Thus, morphologic,

biochemical, and molecular development, with both short- and long-term conse-
quences for systemic and neurobehavioral function emerge as a consequence of
numerous interacting genetic and environmental factors.
11.2 A Brief Introduction to Epigenetics and Development 209

11.2 A Brief Introduction to Epigenetics and Development

Classically, biologists have viewed inheritance and development to be a conse-

quence of our chromosomal heritage, with genotypic specific genes determining
the manner in which phenotypic traits and diseases are handed down from one
generation to another. We now know that this mechanism is only partially correct.
An expanding body of evidence has highlighted the role of environmental factors
that mediate epigenetic mechanisms to modulate embryonic/fetal gene expression.
Thus, for the developing fetus the role of epigenetic influences mediated by mater-
nal stress (whether diet or a number of other factors) may have life-long phenotypic
and behavioral consequences (Paul 2010). In his monumental volume The physiol-
ogy and pathology of exposure to Stress, the McGill University and Université de
Montréal endocrinologist, Hans Selye (1907–1982), observed that stress to the
organism, in essentially any of its forms—dietary, environmental, disease, and oth-
ers—could result in cellular, hormonal, and related damage, with the body mount-
ing a response he termed the “General-Adaptation-Syndrome” (Selye 1950).
Writing years before many of the nuances of biochemical and molecular mecha-
nisms were established, and before the phenomenon of epigenesis was appreciated,
Selye envisioned an orchestrated brain to tissue system-wide biological defensive
response to the challenge of stress of whatever origin. Subsequent investigation has
clarified that while stress of relatively short duration is often followed by successful
adaptation, that of longer duration and/or repeated insult may result in cell damage
and death (Bale et al. 2010; McEwen 2004).
In its broadest sense, epigenetic (from Greek, above, upon, over, or beyond con-
ventional genetic) mechanisms constitute an aspect of cellular/molecular “memory”
of stable, heritable, self-perpetuating, and reversible modifications of chromatin,
that, without alterations in the genomic DNA sequence per se, modulate the on–off
state of gene expression (Bonasio et al. 2010; Devaskar and Raychaudhuri 2007).
Discovery of the phenomenon of epigenetics has added several layers of complexity
to our understanding of the regulation of transcription and translation, and has trans-
formed the way in which we consider gene expression and inheritance (Berger et al.
2009). For the most part, the “memory” of heritable genetic information is encoded
in the sequence of nucleic acids that comprise the DNA of the genome, and which
provides stability and accurate heritability from generation to generation. Genetics
and the environment can interact in germ line mutations of the coding and promoter
regions of genes. In addition, by epigenetic mechanisms cells can inherit and trans-
mit information that is not a part of the genomic sequence. This “hidden” heritabil-
ity of epigenetic processes acts in a cell specific, temporally regulated manner to
direct development, differentiation, organogenesis, and related processes. As a
metaphor, some have compared epigenetic mechanisms to the software that orches-
trates and/or modulates expression of the genomic DNA hardware.
The pioneer University of Edinburgh geneticist and developmental biologist
Conrad Hal Waddington (1905–1975), (Fig. 11.1c) proposed that organismal devel-
opment and response to the environment are regulated by an “epigenetic system”
210 11 Epigenetics and the Fetal Origins of Adult Health and Disease

that sculpts the pathway of embryogenesis. He coined the term epigenetics for the
study of how a wide variety of individual cellular phenotypes arise from a given
genotype, e.g., those events that could not be explained from the principles of genet-
ics, as seen in embryonic development (Waddington 1939, 1940, 1942). Waddington
developed this concept with the metaphor of an “epigenetic landscape” to represent
the process of phenotypic decision making during development from a single
embryonic cell via the alternative pathways to a large number of distinct and dif-
ferentiated cell types (Waddington 1957, 1959). More recently, epigenesis has
been defined as the study of mitotically and/or meiotically heritable changes in
gene function without a change in DNA sequence (Allis et al. 2007; Dolinoy et al.
2007a, b; Russo et al. 1996), or more specifically “the structural adaptation of
chromosomal regions so as to register, signal or perpetuate altered activity states”
(Bird 2007). The contemporary field of “epigenetic epidemiology,” has been
defined “… as the study of the associations between epigenetic variation and risk
of disease” (Waterland and Michels 2007, p. 368). These definitions encompass
aspects such as DNA repair, cell-cycle phases, and those stable changes main-
tained from generation to generation (Anway et al. 2005; Anway and Skinner
2006; Berger et al. 2009; Crews et al. 2007; Lane et al. 2003; Morgan et al. 1999;
Pembrey et al. 2006; Rakyan et al. 2003).
As noted, environmental influences may have profound effects on gene regula-
tion. Many differences in gene expression arise during the course of development
and are retained through mitosis. Such stable, epigenetic changes, which not only
affect development, but can regulate cellular responses, appear to be a consequence
of a “mosaic” of mechanisms, including: DNA methylation, the acetylation, meth-
ylation, and other modifications of histones, the regulation of short RNAs including
microRNAs (miRNA), telomere shortening, alternative splicing, and other mecha-
nisms (Borrelli et al. 2008; Cooney et al. 2002; Franklin and Mansuy 2010; Nanney
1958; Sweatt 2009). In addition, some have applied the term “epigenomics” to the
study of altered chromatin structure, such as complex folding, altered nucleosome
configuration, and related phenomena (Murrell et al. 2005). In turn, the term “nutri
(epi)genomics” has been applied to those sequelae following nutritional alteration
(Tost 2008). Now widely appreciated, even early embryonic development has been
established as a crucial period during which time epigenetic marks are established
(Reik et al. 2001), and a time when the nutritional environment can affect the earli-
est stages of mammalian development (Doherty et al. 2000; Morgan et al. 2008).
Thus, the epigenome, the overall epigenetic state of a cell, constitutes an interface
between genes and the environment, allowing nutritional and a wide variety of
other factors to affect transgenerational adaptation. Several reviews have detailed
some of the vital issues and questions regarding the regulatory mechanisms in this
rapidly evolving field. (For instance see Bernstein et al. 2007; Fagiolini et al. 2009;
Feng et al. 2007; Goldberg et al. 2007; Petronis 2010; Reik et al. 2001; Wadhwa
et al. 2009.)
Of relevance to developmental physiology, one may ask what is the role of epi-
genetics in placental, fetal, and newborn gene expression? During the course of life
and reproduction, cells store information that has been handed down from their
11.2 A Brief Introduction to Epigenetics and Development 211

ancestors, and that will be transmitted to their descendents. For the most part, this
cellular “memory” is encoded in the sequence of nucleic acids that comprise the
DNA of the genome, the genotype or entire compliment of genes that provides the
stability and accurate heritability from generation to generation. Much traditional
research has explored the combined effects of genetics and the environment in germ
line mutations of the coding and promoter regions of genes. One major class of
epigenetic mechanisms termed “cytoplasmic,” is determined by cis-acting factors
associated with DNA methylation, histone modifications and/or the other changes
noted above. DNA with accompanying histones are packaged in nucleosomes, the
core of which contains an octamere of histone proteins. Four basic forms of histones
(H2A, H2B, H3, and H4, as well as minor variants), are encircled by 146 or 147
base pairs of DNA (Finch et al. 1977); a fifth histone, H1, serves as a linker protein
(Bernstein et al. 2007). The histone modifications noted, and DNA methylation,
confer a great increase in the regulatory capacity of each nucleosome, allowing
specific functions such as DNA repair and gene activation to be modulated in the
appropriate manner (Sarma and Reinberg 2005). Enzymes critically associated with
these nucleosomal modifications include DNA methyltransferases, histone acetyl-
transferases, histone methyltransferases, histone deacetylases, histone demethyl-
ases, and others (Dodd et al. 2007; Klose et al. 2006). It is by these nucleosomal
modifications of epigenetic memory, and with their influence on proximate genes,
that genes may be regulated to affect phenotype, without changes in the nucleic acid
code per se (Martin and Zhang 2005; Wolffe and Matzke 1999).
As is becoming increasingly apparent, epigenetic changes play a vital role in
normal cellular function, as well as the development and differentiation of various
cell types (Drake and Walker 2004; Jablonka and Lamb 2002; Monk 1988; Murrell
et al. 2005; Rahnama et al. 2006; Reik 2007). Examples include X-chromosome
inactivation in female mammals, and genomic imprinting in which one parental
allele is altered resulting in parent-of-origin, or random modification of gene tran-
scription (Willard et al. 1993). As noted, the epigenetic state can be disrupted by
maternal environmental influences such as protein deprivation, caloric excess,
hypoxia, and so forth. Also, a wide variety of environmental toxins, including low
dose radiation and psychological stress, have been demonstrated to be important in
epigenetic mechanisms (Dolinoy et al. 2007a, b; Feinberg 2007; Hertz-Piccioto
et al. 2008; Jirtle and Skinner 2007; Pryce et al. 2002; Szyf et al. 2007). Also
increasingly, epigenetic changes are being recognized to be of importance in age-
ing, and the development of cancer and other diseases. Despite the general under-
standing that DNA and/or histone modifications constitute a major factor in the
pathogenesis of epigenesis, a number of questions remain regarding this phenome-
non. For instance, little is known of the molecular mechanisms whereby these
chemical reactions/changes are regulated, the signal transduction mechanisms
involved, the basis for many manifestations not becoming apparent until adult
life, the mechanisms by which they are transmitted between generations, and others.
A plethora of reviews are accessible on this rapidly expanding subject (for instance
see Aagaard-Tillery et al. 2008; Bird 2007; Gheorghe et al. 2010).
212 11 Epigenetics and the Fetal Origins of Adult Health and Disease

11.3 The Dutch “Hunger Winter” of 1944–1945:

A Case Study

As a case study of epigenetics, it may be appropriate to survey the role of antenatal

maternal nutritional restriction with its effects on the fetus and newborn, and the
life-long phenotypic and behavioral consequences in the developing organism, as
experienced during the Dutch “Hunger Winter” of 1944–1945. Of monumental his-
toric importance, a shocking human “experiment” is that which occurred during
World War II, de Hongerwinter in German occupied Western Holland. This mainly
urbanized region of its six largest cities, included four million people, one-half the
Dutch population. Commencing in late September 1944, the famine reached its
peak in February 1945 and continued until the Allied victory in early May. Because
this half-year of Nazi-inflicted starvation occurred during one of the coldest winters
on record, neither food nor fuel could be moved by barges, and the populace lived
without electricity or heat. Mortality more than doubled, accounting for over 20,000
deaths (Burger et al. 1948; Stein and Lumey 2000; Stein et al. 1975a). (This number
does not include the approximately 110,000 Jews deported to concentration camps,
never to return (Trienekens 2000). This German occupation army-induced famine
resulted in the caloric ration falling from ~1,800 to 400 to 800 cal per day. Although
children and to some extent pregnant and lactating women received extra rations
during the early part of this disaster, they too suffered starvation (Roseboom et al.
2001a, 2006; Smith 1947b; Stein et al. 1972, 1975a, b; Susser and Stein 1994)
(Fig. 11.1a and b). Individuals exposed in utero during this tragedy have been traced
in follow-up studies that have provided a number of lessons on the effects of caloric
restriction/malnutrition on subsequent disease prevalence in adulthood (de Rooij
et al. 2007; de Rooij and Roseboom 2010; Lumey et al. 1993; Roseboom et al.
2001a, b; Slager et al. 1985; Stein et al. 1975a, 2007). Not only was the starvation
period clearly defined, and food rations documented, but the population was ethni-
cally homogenous (Burger et al. 1948; Lumey et al. 1993). Beginning in the 1970s,
initial studies were conducted on men conscripted for military service at age 18.
This was followed by studies in the early 1990s of the Dutch national psychiatric
registry, and in the late 1990s and early 2000 analyses in which individuals were
traced from birth records of a given institution. These latter more contemporary
studies of “Dutch Hunger Winter Families” are considered the most definitive
(Lumey et al. 2011).

11.3.1 Maternal and Infant Characteristics

A beneficial unintended consequence of this tragedy is that long-term sequelae have

been defined in terms of the starvation period while in utero, e.g., during early, mid,
or late gestation. Among the cohort of antenatal food deprived adult women, fertil-
ity was halved (Stein and Susser 1975a; Stein et al. 1975a), their weight gain during
11.3 The Dutch “Hunger Winter” of 1944–1945: A Case Study 213

Table 11.1 Maternal and newborn sequelae of Dutch hunger winter

Trimester of exposure
Controla 1st 2nd 3rd Reference
Maternal characteristics
Primiparous (%) 37 43 30 21* Lussana et al. 2008; Painter
et al. 2005a; Roseboom
et al. 2001b, 2003
Weight at end of 68.0 ± 68.4 ± 63.4* ± 62.6* ± Lussana et al. 2008; Painter
pregnancy (kg)b 8.5 8.7 8.0 7.4 et al. 2005a; Roseboom
et al. 2001b, 2003
Weight gain during 3.7 5.7 5.0 0* de Rooij et al. 2007; Painter
third trimester (kg)b et al. 2005a; Roseboom
et al. 2001b, 2003
Newborn characteristics
Birthweight (kg)b 3.4 ± 0.5 3.4 ± 0.4 3.2* ± 0.4 3.1* ± 0.4 de Rooij et al. 2007; Lumey
et al. 1993; Lussana
et al. 2008; Painter et al.
2005a; Roseboom et al.
2001b, 2003, 2006;
Smith 1947b; Stein et al.
1975a, 1995
Birth length (cm) 50.6 ± 2.1 50.9 ± 49.8 ± 1.9 49.4 ± 2.1 Lussana et al. 2008; Painter
2.1 et al. 2005a; Roseboom
et al. 2001b, 2003
Head circumference 33.1 ± 1.6 32.8 ± 32.2* ± 32.3* ± 1.6 Lussana et al. 2008; Painter
(cm) 1.3 1.4 et al. 2005a; Roseboom
et al. 2001b, 2003
Ponderal index 26.4 26.1 26.0 25.8 Painter et al. 2005a;
(kg·m−3) Roseboom et al. 2001b,
2003
Stillbirth rate (%) 2.0 3.5* 2.1 2.0 Stein et al. 1975b
Infant mortality (%) 1.2 2.6* 1.9* 2.4* Stein et al. 1975b
4.0 8.0* Trienekens 2000
*p < 0.05
a
Control values are the mean of values born before and conceived after the famine (Roseboom
et al. 2001a)
b
Mean values of reports of several cohorts of individuals

pregnancy was small (Lussana et al. 2008; Stein et al. 1995), and that during the last
trimester was essentially nil (Lussana et al. 2008; Roseboom et al. 2003) (Table 11.1)
Infants birthweights were significantly lower among those exposed during the
second and third trimesters (the latter being the period of most rapid fetal growth),
with regional variation (for instance, over 340 g less in Amsterdam and about 200 g
less in Utrecht) (Lussana et al. 2008; Roseboom et al. 2003, 2006; Smith 1947a,
1947b) (Table 11.1). In addition to being lighter, shorter, and thinner (Stein et al.
1975a; Stein and Susser 1975c), infants had decreased head circumference; none-
theless, ponderal index (100 × weight in kg × length in m−3) did not differ signifi-
cantly (Roseboom et al. 2001b, 2003). Placental weight and placental index (ratio
of placental to fetal weight × 100) was increased in pregnancies exposed during the
214 11 Epigenetics and the Fetal Origins of Adult Health and Disease

first trimester, suggesting compensatory growth to optimize fetal nutrition. Stillbirth

rates were highest in the cohort experiencing first trimester starvation, while infant
mortality was increased for those exposed at any time during gestation (Stein and
Susser 1975a, b; Stein et al. 1975a) (Table 11.1).

11.3.2 Metabolic Sequelae

Those individuals exposed to famine late in gestation demonstrated impaired glu-

cose tolerance (de Rooij et al. 2006c), with elevated 2-h glucose and insulin values
(Painter et al. 2005a; Ravelli et al. 1998; Roseboom et al. 2001b), insulin secretion
(de Rooij et al. 2006a) and an increase in type 2 diabetes (Kyle and Pichard 2006;
Painter et al. 2005a; Roseboom et al. 2001b, c, 2003) (Table 11.2). Infants exposed
during the third trimester tended to be small throughout their lives. Those normal
weight newborns who experienced starvation during the first trimester, but enjoyed
the benefit of plentiful nutrition following birth, were twice as likely to consume a
high fat diet, and become obese (Stein et al. 2007) with an atherogenic lipid profile
(Lussana et al. 2008) as adults. In females exposed to famine early in gestation both
waist circumference and body mass index (weight in kg × height in m−2) were
increased significantly (Ravelli et al. 1999). The genesis of these and other meta-
bolic changes suggests disturbed hypothalamic-pituitary homeostasis or other cen-
tral mechanisms. Caution must be exercised in interpretation of these results,
however, as the choice of control subjects and sampling variability may have influ-
enced the findings (Stein et al. 2009b). An association also has been shown between
a quantitative fingerprint marker (fingertip ridge count contrast between digits 1 and 5),
which is determined by both genetic and nongenetic factors (Kahn et al. 2008).
In terms of growth per se, one of the best-characterized epigenetically regulated
gene loci is that for insulin-like growth factor II (IGF-2) (Smith et al. 2006). In the
blood of periconceptional exposed survivors, DNA methylation of the igf-2 gene
was decreased significantly, compared to unexposed same sex siblings (Heijmans
et al. 2008), as was that for the promoter region of ins-igf gene, while that for lep
was increased (Tobi et al. 2009). Individuals exposed in mid-gestation also showed
Pro12Ala polymorphism of the peroxisome proliferator-activated receptor-gamma
2 gene (de Rooij et al. 2006b). This was the first evidence in humans that environ-
mental conditions early in gestation can persistently alter epigenetic profiles.

11.3.3 Cardiovascular Sequelae

In concert with the relative prosperity that followed the war, the cohort that experi-
enced first trimester famine demonstrated a significantly greater prevalence of car-
diovascular disease, with an earlier onset of coronary artery disease (Roseboom
et al. 2000a, 2001a, 2006). Despite having normal birthweight, those exposed in
early pregnancy demonstrated atherogenic lipid profiles, suggesting altered lipid
metabolism (Lussana et al. 2008; Roseboom et al. 2000a, 2006) (Table 11.2).
Table 11.2 Metabolic and cardiovascular sequelae of Dutch hunter winter
Trimester of exposure
Control 1st 2nd 3rd Reference
Metabolic sequelae
Plasma glucose 2 h (mmol·1−1)a 5.8 6.1 6.1 6.3* Painter et al. 2005a; Ravelli et al.
1998; Roseboom et al. 2001b
Plasma insulin 2 h (pmol·1−1)aa 170 207* 190 200 Painter et al. 2005a
Impaired glucose tolerance prevalence (%)a 15 16 14 21* Roseboom et al. 2001b
Body mass index (kg·m−2)a 28.9 ± 4.9 28.4 ± 4.7 28.2 ± 4.4 28.5 ± 4.5 Lussana et al. 2008; Ravelli et al.
1999; Roseboom et al. 2001b
Cardiovascular sequelae
LDL/HDL cholesterola 2.5 ± 0.9 2.6–3.3* ± 1.1 2.6 ± 1.1 2.7 ± 0.9 Lussana et al. 2008; Painter et al.
2005a; Roseboom et al.
2000a, 2001b, 2003
Factor VII (% of standard)a 131 117* 133 131 Painter et al. 2005a
Coronary artery disease (%) 3.3 8.8* 0.9 2.5 Ravelli et al. 1999; Roseboom
et al. 2003

Hypertension (Systolic blood pressure, ↑ 0.8 mmHg per Roseboom et al. 1999, 2001d
mmHg) 1 % decrease in
11.3 The Dutch “Hunger Winter” of 1944–1945: A Case Study

protein/CHO
Microalbuminuria ↑ 2× Painter et al. 2005a
Obstructive airway disease (%) 16.4 23.0 24.8* 15.0 Lopuhaa et al. 2000; Painter
et al. 2005a
General health
Perceived poor health (%) 4.9 10.3* 3.7 6.4 Painter et al. 2005a; Roseboom
et al. 2001b, 2003
*p < 0.05
a
Mean values of reports of several cohorts of individuals
215
216 11 Epigenetics and the Fetal Origins of Adult Health and Disease

Women, age 59, exposed at any time showed increased total and low density lipo-
protein (LDL) cholesterol and triglycerides (Lumey et al. 2009). The coagulation
factor VII was decreased following exposure early in gestation (Roseboom et al. 2000b).
Famine-associated differences in mortality may have contributed to these findings,
as those who died may have had differing concentrations of factor VII than those
who survived (Kyle and Pichard 2006). These alterations may reflect disturbed
hepatocyte function, a decrease in their numbers, or other invidious changes.
Overall, while no increase was observed in the prevalence of hypertension in
survivors of intrauterine famine (Roseboom et al. 1999), among individuals who
had been small at birth blood pressures tended to be higher later in life. That ele-
vated blood pressure seen in offspring was shown to be related to lowered maternal
intake of protein in relation to carbohydrate during the third trimester (0.8 mmHg
increase per 1 % decrease in protein/carbohydrate), suggesting a link to macronutri-
ent ingestion (Roseboom et al. 2001d, 2006) (Table 11.2). Men, but not women,
who experienced the famine in utero had a significantly greater prevalence of hyper-
tension associated with enlarged placental surface area, perhaps as a compensatory
mechanism to optimize nutrient transfer (van Abeelen et al. 2011). Both males and
females subjected to deprivation at any period showed earlier onset of coronary
artery disease (Painter et al. 2006c), and decreased common and internal carotid
artery lumen diameter and compliance (Painter et al. 2007a) with decreased thick-
ness of the intima and media (Painter et al. 2007b).

11.3.4 Related Sequelae

That cohort of infants exposed to maternal caloric restriction in mid-gestation, a

time of organ development, developed a greater incidence of obstructive airway
disease with bronchitis and other pulmonary disease (Lopuhaa et al. 2000). They
also gave evidence of renal disease by microalbuminuria with decreased creatinine
clearance (Painter et al. 2005c; Roseboom et al. 2006). In women exposed during
early pregnancy, breast cancer also was increased significantly (Elias et al. 2004b;
Painter et al. 2006a; Roseboom et al. 2006). In terms of general health, at age 50
twice as many of individuals exposed during early gestation perceived themselves
as being less healthy (10.3 %), as compared to controls (4.9 %) (Painter et al. 2005a;
Roseboom et al. 2003) (Table 11.2). In response to a more complete health ques-
tionnaire survey at age 59, preconception exposure to famine was associated with
lower measures of mental and physical well-being (Stein et al. 2009a), although up
to the age 57, no increase in mortality has been shown in either men or women
(Painter et al. 2005b). Also of relevance are the limited findings of individuals
exposed to famine during childhood or adolescence (ages 2–20). In terms of meta-
bolic disease, the mitogenic peptide insulin-like growth factor I (IGF-1) was
increased in adulthood, as was its IGF binding protein, with decreased IGF binding
proteins-1 and -2 (Elias et al. 2004a). Women who suffered starvation during both
prenatal development (Painter et al. 2008b) and childhood (age 2–12) (Elias et al.
2005) were significantly less fertile, and among these (age 2–6) the onset of
11.3 The Dutch “Hunger Winter” of 1944–1945: A Case Study 217

menopause was advanced almost 2 years (Elias et al. 2003). Again, these findings
support the idea that the hypothalamic-pituitary-ovarian axis is particularly sensi-
tive to nutritional deprivation during childhood. Those females exposed to starvation
during childhood (ages 2–9) experienced a significant increase in breast cancer in
adulthood (Elias et al. 2004b). Despite being well fed as they grew into adulthood,
in one study the offspring of survivors (F2 generation) also showed significantly
lower birthweights (Painter et al. 2008a; Susser and Stein 1994).

11.3.5 Neuropsychological Sequelae

Several sub-studies of the Dutch Hunger Winter have focused on neurodevelopmen-

tal defects. Initially among the cohort of 18 year old men subjected to antenatal
famine, no evidence was detected of mental impairment at the time of compulsory
military induction, and this was confirmed in another group that included men and
women at age 59 ± 1 years (de Groot et al. 2011). In contrast, notable among survi-
vors (particularly males) of those conceived during the most severe period of the
famine was a doubling in prevalence of the central nervous system anomalies hydro-
cephalus, neural tube defects with anencephaly, and/or spina bifida (Brown and
Susser 1997; Susser et al. 1996, 1998). Because perinatal mortality was doubled in
this cohort, the prevalence of these disorders may have, in fact, been much greater
(Susser et al. 1996). Using more narrow definitions of famine exposure, spina bifida
was increased only in males, while that for anencephaly was increased greatly in
females (Brown and Susser 1997). Females also demonstrated a significantly higher
prevalence of cerebral palsy, spastic diplegia, and epilepsy (Brown and Susser
1997). An increased prevalence of cerebral palsy among those exposed during the
second and third trimesters (Stein et al. 1975a; Susser et al. 1996) suggests gender
specific nutritional effects.
Another issue of major concern is that among men and women exposed to fam-
ine during the first trimester, schizophrenia (Brown and Susser 2008; Hulshoff Pol
et al. 2000; Susser and Lin 1992; Susser and Stein 1994; Susser et al. 1996, 1998,
2008), and schizophrenia spectrum personality disorders (Hoek et al. 1996) were
increased twofold to threefold. These changes were associated with decreased intra-
cranial volume and an increased number of brain anomalies, including focal hyper-
intensities predominantly in white matter, which may reflect myelin loss (Hulshoff
Pol et al. 2000). These findings stress the critical importance of the early days and
weeks of gestation in neurogenesis and brain development. A more recent study of
men and women, age 56–59 who experienced first trimester nutritional deprivation
disclosed decreased cognitive function, motor-learning, and selective attention
debility that may be ascribed to accelerated cognitive ageing (de Rooij and
Roseboom 2010). The peak incidence of schizophrenia, schizoid personality, and
congenital neural defects occurred in the same birth cohort (Susser et al. 1998).
Also of concern, the prevalence of antisocial personality disorders was increased
significantly among men exposed during the first or second trimesters (Neugebauer
218 11 Epigenetics and the Fetal Origins of Adult Health and Disease

Table 11.3 Summary of long-term sequelae of Dutch hunger wintera

Trimester of exposure
Early Mid Late Childhood
Metabolic Obesity (♀ only) Impaired glucose Impaired ↑ IGF-1 and
tolerance glucose IGFBP-3
intolerance
Cardiovascular Atherogenic
lipid profile
(↑ LDL/HDL
cholesterol)
Altered blood
coagulability
(↓ Factor VII
and
fibrinogen)
Coronary artery Microalbuminuria Hypertension
disease

Neuropsychiatric Congenital Cerebral palsy Cerebral palsy

neural
defects
Schizophrenia
Schizophrenia Affective mood
spectrum disorder
disorders
Substance
dependence
↓ Cognitive
function
Overall Perceived poor ↓ Fertility
health ↑ Breast
cancer
a
Modified from Roseboom et al. 2006

et al. 1999), and the risk of drug addiction was doubled (Franzek et al. 2008).
In addition, men (but not women), exposed during the second and third trimesters
showed a near doubling of other affective mood disorders (Brown et al. 2000),
associated with a significant decrease in head circumference (de Rooij et al. 2010).
Again, these results emphasize the importance of optimal nutrition during the early
periods of neurogenesis and during brain development (Bota et al. 2003). Table 11.3
summarizes the major sequelae of the Dutch Hunger Winter by trimester of expo-
sure, and to a limited extent that nutritional deprivation during childhood.
Because the Hunger Winter occurred at a well-defined time and place, the scope
and severity of the famine was described carefully, and the health effects of birth
cohorts exposed at various times during gestation carefully documented, the
“Dutch Famine Study” has become a classic public health epidemiologic investi-
gation (Kyle and Pichard 2006; Lumey et al. 1993, 2011; Stein et al. 1975a, b;
Susser et al. 1998).
11.5 A Perspective on the Fetal Origins of Adult Health and Disease 219

11.4 Other Antenatal Maternal Starvation Studies

Studies from several other countries under circumstances very different from that in
the Netherlands, suggest the important role of antenatal nutrition and its deficiency
in the pathogenesis of disease in the adult. One of the most severe and devastating
famines in recorded history occurred from 1959 to 1961 in the Wuhu region of
Anhui Province, central eastern China. Precipitated by social turmoil of the “Great
Leap Forward” (Chen and Zhou 2007), by some estimates, 30–40 million people
died (Smil 1999). Similar to studies from the Netherlands, adult offspring of starved
mothers showed a marked increase in prevalence of type 2 diabetes with hypergly-
cemia (Li et al. 2010). In women, the prevalence of obesity also was increased
(Huang et al. 2010), and alarmingly in both men and women the risk of schizophre-
nia was doubled (St. Clair et al. 2005). (For review see Yang 2012.)
Another example comes from Nigeria, in which individuals exposed to famine in
utero and/or during infancy during the war in Biafra (1967–1970) also demonstrated
a significantly increased prevalence of type 2 diabetes and hypertension, with these
sequelae appearing earlier in life and being more severe (Hult et al. 2010). A limita-
tion of this report from West Africa is the lack of birthweight data, and the inability
to separate the effects of famine during fetal life from that of the newborn period.
Although some have questioned the relation of antenatal food deprivation to subse-
quent mental disease in the offspring, given the markedly different ethnic and social
circumstances, the similarity of findings as a consequence of the famines in China
and Nigeria with that in The Netherlands has helped to reinforce the concept that
metabolic and cardiovascular disorders and/or schizophrenia may develop as a con-
sequence of nutritional deficiency during gestation, rather than that of culture, eth-
nicity, or other factors (Neugebauer 2005).

11.5 A Perspective on the Fetal Origins of Adult Health

and Disease

Of relevance to sequelae of the Dutch Hunger Winter and other famines is a brief
consideration of the concept of the developmental origins of adult health and dis-
ease. From the standpoint of physiology of the fetus and newborn infant, the con-
cept of antenatal origins of disease in the adult is of special relevance. As noted, this
is because during the course of gestation a number of stresses to the mother (includ-
ing food deprivation, compromised oxygenation, and exposure to environmental
toxins) may “program” the embryonic and fetal brain, cardiovascular system, and
other organs. “Programming,” constitutes a general process whereby a stimulus or
insult at a critical period of development has lasting or life-long consequences.
As early as the 1930s, in Sweden and Great Britain, the role of the perinatal environ-
ment to mortality as an adult was suggested (Kermack et al. 1934). A mid-century
report from Baltimore noted a familial pattern of doubling of coronary artery
220 11 Epigenetics and the Fetal Origins of Adult Health and Disease

disease associated with sibling stillbirth and infant mortality rates (Rose 1964).
Citing evidence from infancy to adolescence of factors leading to elevated serum
lipids and blood pressure, with impaired glucose tolerance and obesity, in the early
1970s, based on data from the Framingham study of heart disease, two of its leading
investigators concluded that atherosclerosis and coronary artery disease in adults
are a “pediatric problem,” stressing the importance of the pediatrician in preventive
medicine (Kannel and Dawber 1972). From Norway, reports showed a strong cor-
relation between deaths from arteriosclerotic heart disease in men aged 40–69
between 1964 and 1967, and infant mortality one-half a century earlier (Forsdahl
1973, 1977, 1978). From Finland, among men born in Helsinki during the years
1924–1933, those individuals with low birthweight and low ponderal index and
with rapid catch-up growth rates and high body mass index experienced increased
mortality from coronary artery disease (Eriksson et al. 1999).
Commencing in the mid-1980s, the British epidemiologist David James Purslove
Barker (1938–2013) (Fig. 11.1d), currently at the University of Southampton, and
colleagues noted the paradox that, while in general, the rate of cardiovascular
disease increases with prosperity, in an affluent nation it is the poorest who suffer
the highest prevalence of these disorders. In associating the elevated rates of isch-
emic heart disease in adults from England and Wales (from 1968 to 1978), with
birthweights and infant mortality rates half a century earlier (from 1921 to 1925),
they proposed the idea that cardiovascular disease in the adult can have its origins
during antenatal life (Barker 1995a; Barker et al. 1989a, b, 1993; Barker and Martyn
1992; Barker and Osmond 1986a). Soon, the developmental origins concept was
expanded to include type 2 diabetes (Hales et al. 1991), various markers of ageing
(Sayer et al. 1998), and other conditions in the adult (Barker 1995b, 1998a, 2004a,
b; Godfrey and Barker 2001) including breast cancer (Trichopoulos 1990). A proper
interpretation of this relationship was based on several factors, including: the asso-
ciation of neonatal deaths with low birthweight, the role of antenatal versus post-
natal environment, the seemingly paradoxical increase in several diseases with
affluence, and related factors that reflect “… variations in nutrition in early life,
which are expressed pathologically on exposure to later dietary influences” (Barker
and Osmond 1986b, p. 1081). In a study of 3,600 infants born in 1946 in the UK,
birthweight was associated positively with cognitive ability at age 8, and subse-
quently up to age 26, as well as with the level of education achieved (Richards
et al. 2001). In association with effects of maternal nutrition deprivation on the
developing fetus per se, placental growth and development also may be altered, thus
altering the hormonal milieu with subsequent behavioral and hormonal conse-
quences in the adult (Barker 1992, 1994, 2003; Barker et al. 1989a, 1995, 2002;
Gluckman and Hanson 2006; Gluckman et al. 2008). These also include cortisol
secretion later in life (Reynolds et al. 2007; Tu et al. 2007), and immune dysfunction
(Götz et al. 2007; Merlot et al. 2008). Special hallmark features of such antenatal
“programming” include critical periods of vulnerability, failure or unsatisfactory
completion of specific developmental milestones, association with functional
defects, the permanent nature of such sequelae, and its heritability. (A number of
details of the developmental origins hypothesis have been reviewed elsewhere
11.5 A Perspective on the Fetal Origins of Adult Health and Disease 221

(Barker and Clark 1997; Barker and Osmond 1986a, 1986b, 1987; Barker et al.
1989a, 1989b, 1993, 1998a, 1998b; Bateson et al. 2004; Gluckman et al. 2008;
Green and Hanson 2004; Law and Shiell 1996; Lucas et al. 1999; Martyn et al.
1996, 1998; Nijland et al. 2008; Osmond et al. 1993; Painter et al. 2006b).)
Several hypotheses have been proposed to account for the phenomena of genetic
and epigenetic factors influencing fetal/adult growth, development, and long-term
sequelae (Bateson et al. 2004). These include the “thrifty genotype” hypothesis to
explain the origin of type 2 (non-insulin-dependent) diabetes among people as they
become acculturated, adapting western style diets, so that calories could be stored
more efficiently in times of plenty (Neel 1962), and the “thrifty phenotype” hypoth-
esis which postulates that impairment of nutritional supply in early life results in
permanent changes in tissue/organ structure and function to conserve glucose, and
prioritize development of the brain, heart, and other vital organs in infants who
experience intrauterine growth restriction (Hales and Barker 1992, 2001; Ong and
Dunger 2000; Prentice et al. 2005; Stöger 2008). A related hypothesis proposes that
epigenetic alterations in gene expression can be heritable, and may be reversible
(Holness and Sugden 2006).
In laboratory animals, a host of studies have demonstrated a relation between
intrauterine stress to the fetus, particularly that of maternal dietary imbalance,
hypoxia, and/or emotional trauma, and subsequent disease in the adult (Gheorghe
et al. 2010; Gluckman et al. 2008; Hanson and Gluckman 2005; Jansson and Powell
2007; McKinney and Bunney 1969; Robinson 1977). For instance, a considerable
body of evidence is accruing on the role of antenatal protein restriction and disorders
of the systemic renin–angiotensin system (Goyal et al. 2009), as well as that of the
brain (Goyal et al. 2010), lung (Goyal et al. 2011a), pancreas (Goyal et al. 2013) and
placenta (Goyal et al. 2011b), with sexually dimorphic programming of hyperten-
sion (Goyal and Longo 2012). In addition, the studies of Lubo Zhang and colleagues
at Loma Linda University demonstrate the role of antenatal nicotine administration
to pregnant rats in epigenetic responses. Significant alterations include those of:
altered myocardial function (Meyer and Zhang 2007) and susceptibility to ischemia
(Lawrence et al. 2008) the expression pattern of angiotensin-1 and -2 receptors in the
brain (Mao et al. 2008), evidence of oxidative stress and vascular dysfunction (Xiao
et al. 2008, 2011), as well as other significant changes in the adult offspring (Li
et al. 2012). In developed countries, human studies suggest that epigenetic phenom-
ena particularly are discernible when there is mismatch with antenatal inadequacy,
followed by a relative lack of such stress during infant life and childhood (Gluckman
and Hanson 2006). Although a considerable body of phenomenological observa-
tions has been amassed, the fundamental cellular and molecular mechanisms of
“programming” and its effects are largely unknown. In addition, antenatal and post-
natal exposure to environmental toxins (such as ethanol in the genesis of fetal alco-
hol syndrome), and their timing in relation to birth, severity of stress, and duration,
are issues with profound implications for health and disease as an adult (Agin 2010;
Landrigan et al. 2004). The scope of developmental toxicology is beyond the limits
of this essay, however.
222 11 Epigenetics and the Fetal Origins of Adult Health and Disease

11.6 Critiques of the “Fetal Origins” Hypothesis

Despite the evidence noted above, one must acknowledge a number of caveats
regarding the interpretation of these studies. For instance, one may ask which is
worse for mortality risk, nutritional deprivation during fetal development, early
childhood or in adult life. One group suggests that the correlations found between
infant mortality from 1895 to 1908 and adult mortality from various causes from
1969 to 1973 were generally much attenuated or abolished by controlling for indi-
ces of present-day socioeconomic circumstances. They further suggest that the con-
ditions that led to higher infant mortality persisted throughout the adult life of the
geographically located population (Ben-Shlomo and Davey Smith 1991). These
authors also suggest that to determine a definitive basis for the DOHaD hypothesis
requires epidemiologic studies from infancy throughout the full course of life (Ben-
Shlomo and Davey Smith 1991). The DOHaD hypothesis also was tested in a meta-
analysis of 15 longitudinal and four case–control epidemiologic studies which had
supported that hypothesis. Authors of this review rejected the hypothesis, based on
inconsistencies both between and within the reports, inadequate correction for con-
founding factors, and nonspecific relationships (Elford et al. 1991). In a further
critique of ten epidemiologic reports that associated circumstances early in life with
cardiovascular disease in the adult, these authors stressed the invaluable role of
epidemiologic studies in generating hypotheses, as opposed to testing them (Elford
et al. 1992). In conclusion, they noted the failure of these reports to satisfy criteria
for causality, inconsistencies between and within studies, lack of specificity in for-
mulation of hypothesis and the observed relationships, and cautioned that con-
founding variables prevented firm conclusions (Elford et al. 1992). A commentary
in The Lancet also raised a number of the same issues in regards to interpretation of
the data from many of the studies reported (Kramer and Joseph 1996).
A corollary consideration concerns the extent to which malnutrition in utero
determines the occurrence of diabetes and coronary heart disease in adulthood.
Some quote the results from the Leningrad (now St. Petersburg) siege study. In this
cross-sectional study, 169 subjects were exposed to malnutrition in utero (intrauter-
ine group) during the 1941–1944 siege, 192 subjects were born in Leningrad just
before the siege and before rationing began (infant group); and 188 subjects were
born concurrently with the first two groups, but outside the area of the siege (unex-
posed group). The authors concluded that intrauterine malnutrition was not associ-
ated in adulthood with glucose intolerance, dyslipidemia, hypertension, or
cardiovascular disease. The authors did observe a correlation of intrauterine malnu-
trition with systolic blood pressure to body mass index, however, and evidence of
endothelial dysfunction with elevated levels of von Willebrand factor (Stanner et al.
1997). These findings were reiterated in a subsequent report that emphasized the
dissimilar aspects of the Leningrad experience with that in the Netherlands (Stanner
and Yudkin 2001).
A further consideration regards the findings of the Oxford Nutrition Survey in
World War II when examined 50 years later (Huxley et al. 2000). This study comprised
11.7 Malnutrition During Pregnancy as a Global Health Problem 223

two groups of pregnant women in the UK; the first were 120 working-class women
studied in the spring of 1942, the second group included 253 women in 1944
(Huxley et al. 2000). The first group received no nutritional supplementation, while
the second group received such supplementation. Both groups were followed until
after delivery and the offspring were followed for evidence of the fetal origins of
disease hypothesis. The authors found no evidence of an inverse association of low
birth weight with subsequent elevation in blood pressure (Huxley et al. 2000). Two
further reports of the analysis of this data from five decades earlier, arrived at a simi-
lar conclusion, i.e., that birthweight or maternal nutritional status have little rele-
vance to blood pressure levels (Huxley et al. 2002) or coronary heart disease (Huxley
and Neil 2004) later in life. Others also have challenged the DOHaD hypothesis
(Anonymous 1989; Lumey et al. 2011; Whincup et al. 1992).
As has been argued by many, a key consideration in this regard is that one’s
entire “life course” is critical in considering the vast scope of health and disease as
an adult (Elder 1994; Floud et al. 1990; Halfon and Hochstein 2002; Lucas 1991;
Lucas et al. 1999; Lucas and Morley 1994; Lynch and Davey Smith 2005). At the
turn of the century, the International Journal of Epidemiology devoted a special
issue to the “Life Course” approach to chronic disease in the adult. An introductory
editorial outlined the conceptual models of life course epidemiology, distinguishing
“critical” from “sensitive” periods of life, separating individual from inter-
generational determinants of health, and related epidemiologic considerations.
In closing, the authors presented the challenge of elucidating the mechanisms that
account for social, geographical, and temporal patterns of disease distribution in our
societies (Ben-Shlomo and Kuh 2002).
As noted, although a considerable body of phenomenological observations has
been amassed, the fundamental cellular and molecular mechanisms of fetal “pro-
gramming” and its effects as a consequence of malnutrition or other environmental
factors are largely unknown. Clearly, one must move beyond phenomenology to
discover the signal transduction and gene regulation mechanisms that underlie
epigenetic-mediated expression of proteins to account for the several diseases
observed in later life. An additional challenge is to discover those mechanisms that
account for the time lag between exposure during a critical period and the appear-
ance of sequelae many years later. Quite obviously, studies in experimental animals
will be of utmost importance to discover these mechanisms. Analysis of such
reports, even though they are limited, is beyond the scope of this review however.

11.7 Malnutrition During Pregnancy as a Global Health

Problem

Beyond considerations of fetal and newborn development, famine and starvation, of

whatever magnitude or scope, are curses on humankind that must be eliminated at
all cost. As described, the classic “experiment” on the invidious effects of antenatal
224 11 Epigenetics and the Fetal Origins of Adult Health and Disease

famine/malnutrition, the Dutch “Hunger Winter” has provided sobering evidence of

the role of timing and severity of such stress to the embryo/fetus in terms of subse-
quent disease in the adult. In particular, the “Hunger Winter” and its sequelae offers
an appreciation of the effects of nutritional deprivation at specific gestational ages
in affecting one’s “life course” of health and disease. Epidemiologic studies from
the famines in China and Nigeria support these observations. In addition, a report of
increased prevalence of psychological and behavioral problems in offspring of
women who experienced hyperemesis gravidarum, a relatively common condition
of early pregnancy associated with nutritional deprivation cannot be ignored (Mullin
et al. 2012). Thus, it is at our peril that we minimize these reports, for we live in an
age of uncertainty with global threats of major economic or political disruptions in
supply of foodstuffs. These have a clear biological, psychological, and sociological
consequences. Given the prevalence of nutritional deficiencies in pregnant women
throughout the world, one cannot overestimate the importance of ensuring proper
nutrition to attain the full genetic potential of their offspring.
Because optimal nutrition, or the lack thereof, relates so closely to developmen-
tal physiology, the global challenges presented regarding the role of nutrition and
other environmental factors on childhood development are many (Morgane et al.
1993; Olness 2003). Famine and malnutrition are not only a burden on human
health, by leaving in their wake deep seated metabolic, cardiovascular, neural, and
psychiatric disorders, they are an impediment to human progress. As cautioned by
one group, “… for the millions of children around the world who begin their lives
in adverse circumstances, we should be mindful of what is known about sensitive
periods and act with alacrity to improve the lives of these children before neural
circuits become well established and, thus, difficult to modify” (Fox et al. 2010, p.
36). For clinicians, public health workers, and the political establishment both in the
USA and around the globe, a pressing challenge is to confront the growing inequali-
ties among social groups with the widening gap between those of wealth and the
underclass. To ensure optimal systemic, intellectual, and social development of the
next and future generations, our responsibility is to guarantee that every pregnant
mother is provided with proper nutrition for her growing child. Ensuring such opti-
mal nutrition is a realizable achievement. This will not occur, however, by a market-
driven economy, but rather by the determination of healers, the makers of public
policy and the political will of the leaders of nations.

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Chapter 12
Some Aspects of the Developing Brain
and Nervous System

12.1 Overview

As knowledge of human development increases, the sobering reality is becoming

evident that the foundations for much of our life as adults, including our state of
mind and life, are established in our mother’s womb prior to birth. Growth and
development of the brain, the most complex organ not only in the body, but proba-
bly in the universe, is unique in many respects. As with other cells, those of the
nervous system have identical genomic DNA sequences (the template of our hered-
ity and instruction sets for gene expression); however, they develop into strikingly
different and unique phenotypes. Neurons, the cells responsible for signaling, con-
ducting, and communication, convert a variety of stimuli into control of short- and
long-term memory, consciousness, and behavior. By late-gestation in the develop-
ing fetus, following a “brain growth spurt” neuron number is established with only
modest postnatal neurogenesis other than in the dentate gyrus of the hippocampus
and the periventricular and subventricular zones (PVZ and SVZ). Supporting astro-
cytes and glial cells follow a similar course, with a delay of several weeks.
Maturation of oligodendrocytes with formation of myelin follows a much later time
course. In view of the complexity of orchestrated neurogenesis with axon and den-
drite formation during this period of rapid growth, specialized cell type differentia-
tion with their neurotransmitters, migration, the connectivity of literally billions of
synapses, and selective cell death, the brain is exquisitely sensitive to factors that may
alter and interfere with its normal pattern of growth and development.
In terms of cerebral development and gene expression, and their neurophysio-
logic correlates, several issues are of relevance. Beginning shortly following con-
ception, and continuing until at least the third decade of life, development of the
brain with its consequent function is an enormously complicated process, far beyond
the limits of this review. Several fundamental observations may be in order, how-
ever. Brain development, with the main cell lineages neurons, astrocytes, and oligo-
dendrocytes, accomplished by spatial and temporal regulation of specific gene

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 235
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_12, © American Physiological Society 2013
236 12 Some Aspects of the Developing Brain and Nervous System

expression patterns, is crucial for optimal growth, maturation, and this with cogni-
tive maturation. These may reciprocally influence and reinforce one another, and
may be divided into prenatal and postnatal periods. During the 1970s, John Dobbing
(1922–1999) and colleagues of the University of Manchester demonstrated in a
number of mammals that when brain weight is plotted against age, it grows in a
sigmoid trajectory, the transit period of rapid growth being the “brain growth spurt”
(Dobbing 1974; Dobbing and Sands 1973, 1979). Timing of this growth spurt, as
well as its development in general, varies among species. That in precocial species
(of or characterizing those that can ambulate and are relatively independent at birth;
guinea pig, monkey, sheep) occurring prenatally, and as noted earlier that in altricial
or non-precocial species (rat, rabbit, pig) occurring following birth. For humans,
following the first trimester during which period the gross brain shape is deter-
mined, this growth spurt with neurogenesis is intermediate or perinatal, occurring
during both late gestation and early neonatal life (Altman and Das 1965; Bayer
1989; Dobbing 1968; Dobbing and Sands 1973, 1979; Rakic 1975, 2003, 2005).
Because the growth spurt encompasses an enormous number of anatomic,
metabolic, and neurochemical events, each with their behavioral associations, this
critical period of developmental plasticity varies dramatically with cell type and
location. Thus, associated with enhanced vulnerability to nutritional restriction,
hypoxia, or other stress, these are factors that must be taken into consideration when
comparing or extrapolating from one species to another (Altman et al. 1970;
Dobbing 1974; Dobbing and Smart 1974). As emphasized in recent studies, the
concept of the brain “growth spurt” may, in fact, be misleading, as each brain region
with their specific cellular units has a unique period of neurogenesis, neural migra-
tion, synaptogenesis, myelinization, and gliogenesis. These events, occurring “…
prior to the major growth spurt cannot be ignored since this … cell division growth
spurt, is a transient window of neurogenesis for the total macroneuronal population,
which is ultimately responsible for the development of the larger circuit formations
and for the basic architectonic organization of the brain” (Morgane et al. 1993, p.
98). For instance, several lines of evidence demonstrate electrocortical activity
(Aresin 1962), neurophysiologic function in the brain stem respiratory center
(Windle et al. 1938), as well as spinal motor reflexes (Windle and Fitzgerald 1937),
as early as 3 months gestation. Complicating this scenario is the fact that the devel-
opmental profile may differ significantly in the premature newborn infant, as com-
pared with that of the full-term infant (Kosmarskaya 1963), and a host of factors
may alter other aspects of development (Windle 1967). Several reviews include
detailed summaries of specific developmental events in the human brain (for
instance see Williams 1989).
At the time of birth, the human brain weighs ~350 g, that is about 10 % of body
weight, but it accounts for about one-quarter of the basal metabolic rate (Holliday
1971; Williams and Herrup 1988). In proportion to whole body mass and metabo-
lism, the brain of the fetus is relatively large, comprising about 27 % of adult brain
weight, with its mass continuing to increase in the infant and child largely as a result
12.1 Overview 237

of myelin deposition (Davison and Dobbing 1966; Dobbing and Sands 1973, 1979).
Because a number of physiologic adaptations tend to protect the developing brain,
in the infant with nutritional deprivation or other causes of intrauterine growth
restriction, the brain and head size are relatively preserved, with “brain sparing,” in
relation to body size and girth (Dobbing 1981). The human cerebral cortex consti-
tutes six laminated layers of neurons with arrays of intersecting radial columns.
During development, excitatory projection neurons that originate from the prolif-
erative periventricular zone or subventricular zone of the embryonic cerebral vesi-
cles migrate along elongated radial fibers to form the vertically oriented radial
columns (Mountcastle 1997; Szentágothai 1978; Torii et al. 2009). Of fundamental
importance in terms of development and providing scaffolding for neuronal migra-
tion and terminal location, are cortical radial glial cells, a distinct cell class which
display unique features in each species studied (Rakic 2003). Such neural develop-
ment and diversity is determined by several major factors which can vary consider-
ably, including: the number of stem or precursor cells from which the population is
derived, the duration of the regional proliferative period, and the cell cycle duration
(McConnell 1991; Sur and Rubenstein 2005; Williams 1989).
Cerebral cortical development with its many nuclei, tracts, and other structures
must proceed in an exquisitely orchestrated progression of cell migration and dif-
ferentiation, with the complement of neurons being relatively complete at the time
of birth, while glia and astrocytes continue to develop at a more leisurely pace
(Takizawa et al. 2001). By 2 years of age brain volume has achieved 80–90 % of its
lifetime maximum (Pfefferbaum et al. 1994), with increasing myelination continu-
ing into and beyond young adulthood (Sowell et al. 2004). In primates, the perinatal
period sees the emergence of unique cellular patterns, cytoarchitecture, and neuro-
chemical maturation. Throughout adolescence, this is followed by further neuronal
growth and differentiation with synaptogenesis and circuit organization (Levitt
2003). As may be self evident, synaptogenesis, with orchestrated development of
the synapses per se, the presynaptic and postsynaptic neurons with their neuroligand
and neurolexin connecting cell-adhesion molecules, their vesicles of neurotransmit-
ters and other specialized features, are critical for neuronal function and cognition
(Soler-Llavina et al. 2011; Südhof 2008). Importantly, glial cell number appears to
be adjusted proportionally to match the neuronal population (Williams and Herrup
1988). During the time of rapid neuronal growth in the last trimester of pregnancy,
the cerebral, so called, “resting state networks” (as determined by functional mag-
netic radiation imaging), although developing at different rates for various systems
(visual, auditory, somatosensory, motor, and others), are mature near-term, prior to
experiencing or being a consequence of related cognitive functions (Doria et al.
2010). Despite the remarkable advances of contemporary neuroscience and dedi-
cated study during the 1990s “Decade of the Brain” (Goldstein 1994) and beyond,
we are only in the infancy of understanding nuances of cerebral development and
function (Aguirre et al. 2010; Bota et al. 2003; Edlund and Jessell 1999; Guillemot
et al. 2006; Jessell and Sanes 2000; Price et al. 2006; Rakic 2005).
238 12 Some Aspects of the Developing Brain and Nervous System

12.2 Developmental Neurogenesis

Also at mid-century, Donald Olding Hebb (1904–1985) of McGill University pos-

tulated that “adaptability” or “plasticity” of the developing brain was accomplished
by “strengthening synapses,” in the absence of structural reorganization (Hebb
1949). In the early 1960s, Roger Wolcott Sperry (1913–1994) of the California
Institute of Technology, proposed a “chemoaffinity” theory in which,
… the establishment and maintenance of synaptic associations were conceived to be regu-
lated by highly specific cytochemical affinities that arise systematically among the different
types of neurons involved via self-differentiation, induction through terminal contacts, and
embryonic gradient effects…. A necessary conclusion from these results [is] that the cells and
fibers of the brain and cord must carry some kind of individual identification tags, presumably
cytochemical in nature, by which they are distinguished one from another almost, in many
regions, to the level of the single neuron; and further, that the growing fibers are extremely
particular when it comes to establishing synaptic connections, each axon linking only with
certain neurons to which it becomes selectively attached by specific chemical affinities.
(Sperry 1963, pp. 703–704)

Sperry’s idea was that selected molecules would serve as labels or markers that
direct migration and the formation of unique patterns of synaptic connections
between and among neurons, to establish “… the developmental pattern of central
nervous organization” (Sperry 1963, pp. 703–704). In 1981, Sperry was awarded
the Nobel Prize in Physiology or Medicine for his perceptive studies concerning the
functional specialization of the cerebral hemispheres.
During the era of Sperry’s contributions, Joseph Altman of the Massachusetts
Institute of Technology, first proposed continued neurogenesis in the adult brain,
with structured plasticity (Altman 1962). Later, axonal elongation and synaptic
reorganization were demonstrated in response to injury (Raisman 1969), and soon,
it was shown that experience alone could affect structural changes in presynaptic
and postsynaptic neurons (Greenough et al. 1978). In support of Sperry’s hypothesis
of neural cytochemical affinities, studies during the past decade have established the
role of Down syndrome cell adhesion molecule (DSCAM) and related proteins in
determining specific neural connections (Matthews et al. 2007; Schmucker et al.
2000; Wojtowicz et al. 2007). A galaxy of DSCAM isoforms are essential for a
robust system of orchestrating the complexity of self-avoidance and normal axonal
and dendritic patterning (Hattori et al. 2009; Zipursky 2010). In support of
Altman’s hypothesis, in the adult brain of many species, stem cell (e.g., progenitor
cell-derived) neurogenesis continues in the periventricular and subventricular
zones, (Reynolds and Weiss 1992; Richards et al. 1992), and in the subgranular
zone of the dentate gyrus of the hippocampus (Gage et al. 1995; Kriegstein and
Alvarez-Buylla 2009; Kuwabara et al. 2009; Ming and Song 2011; Palmer et al.
1997; Suh et al. 2007; Zhao et al. 2008).
The extracellular matrix, its proteins, and integrin cell surface receptors also play
a critical role in neurogenesis and axonal guidance (Garcion et al. 2001; Rønn et al.
1998). Assumptions of the extent to which these findings in laboratory animals
apply to humans need to be reassessed, however. Studies of human surgical and
autopsy brain specimens, from birth to ninth decade of life, disclose that the
12.2 Developmental Neurogenesis 239

Fig. 12.1 (a) David Hunter Hubel. (b) Torsten Nils Wiesel. (c) Charles Judson Herrick (1868–
1960). (d) Jean William Fritz Piaget (1896–1980). (e) Lloyd Alexander Jeffress (1900–1986)

migratory cell stems that originate in the SVZ, while present in newborn infants,
disappear by the 18th month of life (Sanai et al. 2011). The authors also describe for
the first time large number of tangential migratory neurons, originating in the SVZ
and destined for the olfactory bulb, that coalesce into the medial branch of a rostral
migratory stream that reaches the ventromedial prefrontal cortex (Sanai et al. 2011).
Many intricacies of neurogenesis in developing and adult brain, and the regulation
by cell intrinsic programs and cell external cues, have been reviewed by others
(Cohen and Greenberg 2008; Edlund and Jessell 1999; Gage 2000, 2002; Kinter
2002; Qian et al. 2000; Rakic 2000, 2003).
As noted above, in the early- to mid-1960s, several important contributions were
made to the cellular aspects of brain development and neuronal myelinization, and
some aspects of their relation to maternal nutritional status (Davison and Dobbing
1966; Dobbing 1974; McIntosh et al. 1979). In addition, a monumental series of
experimental studies contributed to understanding the importance and basis of criti-
cal periods in neural development. At this time David Hunter Hubel and Torsten
Nils Wiesel, at Harvard Medical School (Fig. 12.1a, b), described the organization
of neural circuits in the primary visual cortex where information from the retinas is
240 12 Some Aspects of the Developing Brain and Nervous System

processed. They identified an aspect of neural organization crucial for combining

information from the two eyes to reconstruct accurately the three-dimensional
world. In these studies, they detailed the manner in which nerve axons from the
thalamus, the brain’s relay center for visual information received from the retina,
fan out into a broad band to terminate in the visual cortex in alternating eye specific
zones referred to as cortical ocular dominance columns.
Hubel and Wiesel also performed a series of experiments in which they demon-
strated that following birth, suturing the eyelids closed over the eyes of kittens for
2–3 months, severely impaired development and maturation of neurons of the visual
cortex and cells in the lateral geniculate body, altering the structure of the cortical
ocular dominance columns (Wiesel and Hubel 1963a). As a consequence, even
though the eyes were uncovered within a few weeks, the animals were blind. In
contrast, suturing the lids of one eye shut resulted in cells that would have fired in
response to the closed eye instead responded to the open eye, thereby resulting in
amblyopia. Shutting the eye of an adult cat did nothing, demonstrating that visual
cortex cells were programmed during a critical developmental window during the
first weeks to month of life. This research demonstrated clearly that in the sensory
development of the brain, early visual experience plays a critical role in the origin
of visual cognition, and that the relative level and synchrony of activity exerts a
powerful influence on the development of brain circuitry. The concept that “neurons
that fire together wire together,” subsequently was supported by several lines of
evidence. These and other studies led to the idea that synchronous presynaptic and
postsynaptic activity could couple release and uptake of synaptotrophins, thereby
modulating synaptic connections (Hubel and Wiesel 1965; Snider and Lichtman
1996; Wiesel and Hubel 1963b). For their discoveries concerning neurogenesis and
the visual system, Hubel and Wiesel shared with Roger Sperry the 1981 Nobel Prize
in Physiology or Medicine (Hubel 1982; Wiesel 1982).
A 1964 3 day symposium in Paris, Regional development of the brain in early
life, was organized jointly by the Council for International Organizations of Medical
Sciences and the Délégation à la Recherche Scientifique et Technique. This multi-
disciplinary gathering included a number of prominent neuroanatomists, histolo-
gists, neurochemists, physiologists, electrophysiologists, and clinicians. In addition
to sharing their latest findings on brain development, their goal was to compare
methodologies and approaches, and to develop meaningful collaborations among
scientists from different disciplines (Minkowski 1967). Contributions included sev-
eral dozen aspects of neurogenesis, myelinization, synaptic development, the role of
nerve growth factors, enzyme and neurotransmitter activities, and electrophysio-
logic correlates (Minkowski 1967).
In 1970, Marcus Jacobson (1930–2001) of Johns Hopkins University, synthe-
sized contemporary ideas from organ systems, cellular, and subcellular studies on the
development of the nervous system in vertebrates as well as invertebrates, stressing
the organization of various aspects of neuronal function (Jacobson 1970). Less than
a decade later, he updated this synthesis with recent discoveries placed within the
context of the historical evolution of concepts and understanding (Jacobson 1978).
12.2 Developmental Neurogenesis 241

More recent studies have confirmed that normal development of the visual
cortex depends critically upon appropriate neural information being transmitted
from the retina (Rakic 1976, 1988; Rakic and Riley 1983), and rather than being
preprogrammed, this development is very much experience-dependent (Jandó
et al. 2012).
For neurons and other brain cells, among the most sophisticated in the body,
despite the differentiation signal having been experienced only once during the ear-
liest development, cell identities are maintained for a lifetime (Ringrose and Paro
2004). Much of this developmental gene switching on and off in the transition from
a single fertilized cell to fully formed organism follows elegantly orchestrated and
regulated epigenetic mechanisms (Bale et al. 2010; Borrelli et al. 2008; Jiang et al.
2008). For the major brain cells, deviation in the normal pattern of gene expression
from neural progenitor cell to mature neuron or glia may lead to altered phenotype,
and such altered gene expression may be evidenced by neuropsychiatric disorders.
(This occurs as well in laboratory animals, which display numerous lethal embry-
onic null mutants.) As can be appreciated, because of the complexity and specificity
of neural regulatory circuits, classical analysis of individual genes or genome-wide
analysis in whole brain, or its major parts, is inappropriate.
Gene regulation per se in development of the brain is beyond the scope of this
chapter; however, a consideration of some basics may be relevant. During the past
several decades, studies in the mouse, with many genes and cell lineages similar to
the human, have revealed a number of fundamental molecular mechanisms with
the proneural and other genes required underlying brain development. These
include: aspects of cell differentiation with neural induction from precursor cells in
the neural plate, regionalization of the neural tube along the dorsoventral and
anteroposterior axes, neurogenesis with generation of neurons, astrocytes, and oli-
godendrocytes from multipotent progenitor stem cells located in the SVZ of the
embryonic neural tube, the regulation of selective neuronal survival and apoptosis,
the regulation of neural cell migration with patterning and guidance to site of func-
tion, the acquisition of differentiated features, the formation of synapses among
appropriate neurons with development of circuitry, and others. The cerebral cortex
is composed of two major neuronal populations; projection or pyramidal neurons
are glutamatergic and excitatory utilizing N-methyl-d-aspartate (NMDA) recep-
tors, while inhibitory interneurons utilize the neurotransmitter gamma-aminobu-
tyric acid (GABA) and its receptors (Guillemot et al. 2006; Jessell and Sanes 2000;
Price et al. 2006; Smith and Greenfield 2003). Recent evidence suggests that
GABA also plays a critical role in the development of neural progenitor cells (Yuan
2008). In the brain, as in all organs, interactions among gene, gene products, and
small molecules are responsible for the regulation of all cellular processes, includ-
ing those of cell survival, proliferation, and differentiation. These interactions are
organized into complex lattice structures and/or networks that modulate intracel-
lular signaling, metabolism, and gene regulation. In terms of regulatory mecha-
nisms, it is clear that these involve complex gene regulation by a number of
transcription factors.
242 12 Some Aspects of the Developing Brain and Nervous System

12.3 Cognitive Development

The relation of development of the brain to cognitive development is, quite obvi-
ously, a vital area of consideration. Because of its complexity, extensive literature,
and somewhat peripheral relation to fetal-neonatal physiology per se, however, it
cannot be considered at length (see Nelson et al. 2006). Pioneer work on develop-
ment of the nervous system in vertebrates commenced with the monumental studies
of George E. Coghill of the University of Kansas and the Wistar Institute of Anatomy
and Biology, Philadelphia. Working chiefly with larva of the salamander Ambystoma,
over several decades Coghill formulated a “universal law” that the overall pattern of
development of the central nervous system and associated behavior (integrative
action) dominates the partial or individual sequential patterns (reflex or analytical
action). That is, the organism is not the sum of its localized reflexes, but rather “a
totally integrated matrix.” As with his contemporary Joseph Needham, Coghill
rejected metaphysical vitalism, appreciating that embryology, as a science, arose
from the domain of morphology. However, in contrast to Needham’s biochemical
perspective, Coghill held that it was from a behavioral vantage point that physiologi-
cal implications of complete integration could be understood (Coghill 1929). Coghill
recognized the possibilities of fresh discoveries and insights, with concepts such as,
… totipotence, pleuripotence, organizers, gradients, all of which have meaning only as the
organism is regarded … as a dynamic pattern in time … the neuron-embryologic study of
behavior shows that events within a behavioral system can be understood scientifically only
as their relation is known to subsequent as well as antecedent phases of the cycle.
(Coghill 1933, p. 137)

Coghill concluded this essay with his credo,

My own working hypothesis holds that the relation of cause and effect, in a purely scientific
discipline, is a space-time relation within a unitary system, that the living organism is such
a system, and that I can not fully perceive any phase of this relation or part of this system
without perceiving the system as a whole. Upon this hypothesis my understanding of an
even scientifically or experimentally requires knowledge of the future as well as of the past
of the system in which that event occurs. If this be philosophy, I would call it a philosophy,
not of being, but of becoming; not of life, but of living – which is itself my supreme
experiment.
(Coghill 1933, p. 138)

In his 1928 lectures at University College London, Coghill summarized these

concepts, presenting the background for his passion to perform studies in parallel on
the development of behavior in combination with morphologic studies on nervous
system development. As noted earlier, it was Donald Barron’s knowledge and
appreciation of Coghill’s studies in the salamander that prompted him, upon meet-
ing Joseph Barcroft in 1934 and learning that he had purchased a large number of
pregnant ewes, to ask whether he proposed to study the development of the nervous
system in the mammalian fetus. Nonplussed by this question, but intrigued, Barcroft
asked Barron to “… tell him [all] about it.” This seminal event in the genesis of the
disciplines of fetal physiology illustrates its cross-disciplinary nature (Coghill
12.3 Cognitive Development 243

1929). As an aside, in 1937 Coghill with Wolfram Karl Legner (1902–1981) pub-
lished an English translation of one section, “Embryonic Motility and Sensitivity”
of Preyer’s Specielle Physiologie… (Preyer 1937). Preyer’s The mind of the child…
also was translated into English (Preyer 1901).
A mentor of Coghill was Charles Judson Herrick (1868–1960) (Fig. 12.1c), of
the University of Chicago. Influenced greatly by his elder brother Clarence Luther
Herrick (1858–1904), who died early in his career, “CJ,” as he was known by
friends, dedicated himself to integrating several disciplines in understanding the
nervous system. With detailed histologic analysis, combined with functional studies
of the Tiger salamander and primitive mammals, Herrick established the brain as a
“working mechanism,” with the nervous system organized for responses of the body
as a whole (Herrick 1924, 1926, 1929). A “behaviorist,” near the conclusion of his
life he expressed his views on humanity’s responsibilities in regards to conduct and
contribution to civilization, concepts that are relevant half a century later. In the
conclusion to his introduction Herrick affirmed,
I did not devote sixty years to intensive study of the comparative anatomy of the nervous
system merely to collect dead facts or add to the score of “accumulative knowledge.” I
wanted to find out what these animals do with the organs they have and what they do it for,
with the expectation that this knowledge would help us to unravel the intricate texture of the
human nervous system and show us how to use it more efficiently. The unflagging toil of
hundreds of qualified experts in diverse fields of science has abundantly fulfilled this expec-
tation, but we have disastrously failed to apply the knowledge to anything even resembling
successful treatment of the disordered behavior that now prevails in our troubled world. We
can do better if we really want to and are willing to pay the price.
(Herrick 1956, pp. 7–8)

In addition to other honors, Herrick was a member of the National Academy of

Sciences (Bartelmez 1973). Founding of the American School of Psychology has
been credited to the Herrick brothers in collaboration with Coghill (Roofe 1971).
Perhaps the most satisfactory theoretical treatment of the concept of neural-based
hierarchic order was given by Paul A. Weiss, whose experimental studies of the
semi-aquatic salamander of the genus Triturus (newt) provided Coghill’s concepts
with a solid empirical basis.
The mid-twentieth century witnessed the waning of behaviorism, and the gradual
ascendance of cognitive psychology. Two important contributions to a widened
understanding of development of the nervous system and cognitive psychology
were the 1948 Hixon Symposium Cerebral mechanisms in behavior at the California
Institute of Technology, and the Dartmouth Conference on Learning Theory held
2 years later. The Hixon Symposium chaired by Lloyd Alexander Jeffress (1900–
1986) (Fig. 12.1e) of the University of Texas, Austin, and Henry Walker Brosin
(1904–1999) of the University of Chicago (and later at Pittsburgh), included dozen
and a half of the most outstanding cognitive scientists in the world. Also attending
were individuals from emerging fields of cybernetics and information processing
such as the mathematician John von Neumann (1903–1957) of the Institute of
Advanced Study, Princeton University, who was involved with, among other things,
development of the first electronic computer, ENIAC, and the future two time Nobel
Laureate chemist Linus Carl Pauling (1901–1994) of the California Institute of
244 12 Some Aspects of the Developing Brain and Nervous System

Technology. Another participant was Warren Sturgis McCulloch (1898–1969) of

the University of Illinois, Chicago, and later the Massachusetts Institute of
Technology. A neurophysiologist, McCulloch was interested in parallels between
the nervous system and logical machines, and in his papers such as “A logical cal-
culus of the ideas immanent in nervous activity” (McCulloch and Pitts 1943) con-
tributed to neural network theory, the theories of automata and cybernetics, and
provided a foundation for certain theories of the mind. For the most part the partici-
pants challenged the inadequacies of behaviorism, sparking a new direction of psy-
chological thought and thinking in regards to development of consciousness and the
mind (Jeffress 1951). In a discussion of “The problem of serial order in behavior,”
Weiss observed,
… while the physiologist and psychologist deal with the ready-made machine of the ner-
vous system … the embryologist must explain just how such an immensely intricate, yet
orderly, thing can develop, … the relative autonomy of structural patterns of activity, and
the hierarchical principle of organization … the nervous system is not one big monotonic
pool whose elements can be freely recombined in any number of groups, thereby giving an
infinite variety of nervous responses …. The working of the central nervous system is a
hierarchic affair in which functions at the higher levels do not deal directly with the ultimate
structural units, such as neurons or motor units, but operate by activating lower patterns that
have their own relatively autonomous structural unity …. The principle point is that the
rhythm is not something generated through an input rhythm, but is itself a primary rhythm
which may be released and even speeded up or retarded by the input, but is not derived from
the input. So we have experimental evidence that autonomy of pattern, rhythmic automa-
tism, and hierarchical organization are primary attributes of even the simplest nervous sys-
tems, and I think that this unifies our views of the nervous system.
(Weiss 1951, pp. 140–142)

A member of the National Academy of Sciences (1947), in 1979 Weiss was

awarded the National Medal of Science (Overton 1997). At the Dartmouth confer-
ence/seminar the participants considered the current status, and problems with, the
theories that occupied dominant positions in the field of learning theory of five dis-
tinguished cognitive psychologists. Sigmund Koch (1917–1996) of Duke University
identified many inadequacies in the hypothetico-deductive behavioralist system.
Other participants noted weaknesses of other theories of learning, particularly as
they failed to meet the necessary and sufficient criteria for a theory, as required by
the then prevailing philosophy of science, logical positivism (Estes 1954).
Another pioneer in the field of cognitive development was Jean William Fritz
Piaget (1896–1980), (Fig. 12.1d) of Geneva’s International Bureau of Education,
and later with the International Centre of Genetic Epistemology which he founded
(1955) and directed. From his studies in infants and children, Piaget postulated that
individuals pass through stages of development regarding several operational stages
or models (biological, sociological, sensorimotor/adaptive, logical and figurative
thought) which allow them to think in new, more complex manners (Piaget 1936,
1953 and 1937, 1954). Although many of Piaget’s theoretical claims have been
discredited, phenomena he discovered such as object permanence during infancy
and the developing complexity of conversations in children, continue to attract
12.4 Cerebral Blood Flow in the Fetus and Newborn 245

interest (Walkerdine 1987). Another controversy in cognitive development’s early

years was that of “nature versus nurture,” or nativism versus empiricism. As now
recognized, this is a false dichotomy in light of the tsunami of research supporting
the role of epigenetics and other factors in gene activity and the development of
neurons and other brain cells (see Davies 2001).
A related area of cognitive development, is that of ante- and post-natal influences
on cognition, learning, and function. The psychologist and director of the Institute
for the Study of Child Development at the Robert Wood Johnson Medical School,
University of Medicine and Dentistry at New Jersey, Michael Lewis has focused on
several aspects of intellectual development, and the challenges of their understand-
ing. His edited 1986 volume Learning disabilities and prenatal risk, includes major
sections on prenatal factors (drugs, pollutants, smoking, drinking, and undernutri-
tion) and perinatal factors (maternal medications, obstetrical trauma, and infections)
on brain development and compromised cognition and learning (Lewis 1986).

12.4 Cerebral Blood Flow in the Fetus and Newborn

As one of the, if not the most, important organs in the body, and as an illustration of
the regulation of blood flow during development, it may be appropriate to consider
briefly that to the brain and the extent to which the regulatory mechanisms differ
from that of the adult. Cerebral blood flow (CBF) is the complex, multi-feedback,
integrated response to numerous regulatory influences including: transmural pres-
sure gradients, shear stress, and perivascular neuronal activity as well as chemical,
endocrine, and metabolic factors originating in the brain and circulating blood
(Bevan and Bevan 1981, 1994; Busija and Heistad 1984). The “holy grail” of cere-
brovascular biology and essence of homeostasis is the hierarchy of regulatory
mechanisms that couple CBF to tissue metabolism. In contrast to the idea that the
fetus and newborn are simply small adults, it is critical to remember that not only do
stimuli reaching immature cerebral arteries differ from those of the adult, but so too
the responses of these vessels to those stimuli differ dramatically (Bevan et al. 1980;
Duckles and Banner 1984; Goyal and Longo 2012; Goyal et al. 2009, 2012; Longo
and Goyal 2013; Longo et al. 1996a, 1996b, 2000; Pearce et al. 1991, 1999, 2003).
As for the adult, the maintenance of well-regulated cerebral vascular tone and
blood flow is essential to the developing organism. For the fetus and newborn infant,
in part, this is because the brain is uniquely susceptible to a broad variety of injuries
and insults, the majority of which culminate in diverse patterns of encephalopathy.
A major pathogenic factor in these disorders is dysregulation of cerebral blood flow
with intracerebral hemorrhage. Hemorrhage into the germinal matrix and periven-
tricular region, which occurs in about 2–5 per 1,000 live births, is associated with
the development of spastic motor deficits associated with cerebral palsy, convulsive
disorders, and other neurological diseases (Doyle et al. 2010; Groenendaal et al.
2010; Munck et al. 2010; Sheth 1998), and/or with cognitive attention deficiencies
(Aarnoudse-Moens et al. 2009; Del Toro et al. 1991; Johnson et al. 2010; Msall
246 12 Some Aspects of the Developing Brain and Nervous System

2010). Among very preterm and very low birth weight (<32 weeks gestation; <1,500 g)
and extremely preterm and extremely low birth weight (<28 weeks gestation;
<1,000 g) infants the prevalence of brain damage is particularly high (Ferriero 2004;
Stoll et al. 2010; Vannucci and Vannucci 2004; Volpe et al. 2011). The consequent
pathology can result in severe neurological sequelae with lifelong personal, social,
and economic consequences. Because of their major clinical relevance, cerebrovas-
cular responses to ischemia, hypoxia, hypercapnia, and other pathophysiological
stresses have attracted considerable investigative effort. Nonetheless, many funda-
mental issues regarding CBF regulation in response to increased neuronal activity
and other physiological stimuli remain uncertain, which complicates understanding
of how this regulation changes with development.
During the past several decades, studies have revealed important aspects in the
fundamental signaling transduction mechanisms that regulate cerebrovascular con-
tractility of smooth muscle cells (SMC) in the course of maturational development
(Goyal et al. 2009, 2010a, 2010b; Longo and Goyal 2013; Longo et al. 1996a,
1996b, 2000; Pearce et al. 1999; 2003). Some of these important mechanistic differ-
ences include unique features of the relation of function to structure (Goyal et al.
2012), the role of endothelium-mediated prostacyclin and eicosanoid, nitric oxide
and cyclic nucleotide relaxation mechanisms (Leffler et al. 1999, 2001, 2005).
In terms of contractile mechanisms, the relatively immature organism is characterized
by the unique role of calcium (Ca2+)-dependent receptor-second messenger cou-
pling with plasma membrane L-type Ca2+ channels showing a virtual dependence of
the immature organism on extra-cellular Ca2+ (as opposed to intracellular Ca2+ stores
in adult) for Ca2+-dependent thick (myosin) filament regulation (Blood et al. 2002;
Long et al. 1999; Nauli et al. 2000). In addition, plasma membrane K+ channels (in
particular the big conductance calcium sensitive potassium (BK) channel) play a
major role in regulating Ca2+ entry into the fetal cerebral SMC (Long et al. 2000a,
2000b). The BK channel in the fetus shows greater conductance, and is more sensi-
tive to intracellular Ca2+ concentration (i.e., has a lower Ca2+ set point) (Lin et al.
2003). The BK channel in fetal cerebral arteries show more activity to protein kinase
G (PKG) phosphorylation, in contrast to the adult which show more activity to pro-
tein kinase A (PKA) phosphorylation (Lin et al. 2005, 2006). Additionally, Ca2+
stores in fetal SMC sarcoplasmic reticulum demonstrate much less releasable Ca2+
than adult, either en masse or as “sparks,” thus accounting, in part, for the develop-
ing cerebrovasculature being more dependent on extracellular Ca2+ for contraction
(Long et al. 1999, 2000b). Also in the developing fetus, the relative density of
alpha1-adrenergic receptor subtypes (A, B, D) are much less than that of the adult.
These also differ strikingly in their responses, the B and D subtypes being more
responsible for trophic responses (Goyal et al. 2010b). Additionally, many elements
of the non-Ca2+-dependent pathway of protein kinase C (PKC) to specific enzymes
such as the mitogen-activated protein kinase (MAPK) cascade, extracellular regu-
lated kinases (ERK1/2), and the downstream effectors Rho A, Rho kinase (ROCK),
myosin light chain20 (MLC20) and others, differ dramatically in the fetus, compared
to adult (Goyal et al. 2009, 2010a; Longo et al. 2000). For instance, compared to
adult cerebrovascular SMCs, which show little activity of Rho kinase-mediated
12.4 Cerebral Blood Flow in the Fetus and Newborn 247

mechanisms, fetal arteries show great dependence on ROCK. In turn, developing

SMC lack the adult sensitivity to CPI-17 inhibition of MLCP (Goyal et al. 2009).
Of particular significance, based on these and other studies, compared to the more
mature vessels, those of the developing organism display much greater Ca2+ sensi-
tivity for contraction. Thus, in terms of overall regulation one may postulate a “ying
and yang” phenomenon, wherein a combination of elevated Ca2+ sensitivity and
reliance on extracellular Ca2+ characterize early development, whereas the mature
adult cerebrovasculature is dependent on intracellular Ca2+ stores with decreased
Ca2+ sensitivity. Also compared to adult SMCs, those of the developing fetus and
newborn demonstrate manifold differences in gene regulation of critical signal
transduction pathways (Goyal and Longo 2012).
Taken together, these studies demonstrate profound differences in cerebral artery
relaxation/contraction mechanisms as a function of developmental age, and empha-
size the need to understand the biochemical and molecular basis of these changes.
Further complicating cerebrovasculature maturation, is the marked heterogeneity
observed among vessels from different species, arteries of different size, and among
similarly sized arteries from different vascular beds. Nutritional history and health
status also have an important bearing, not only on vascular characteristics per se, but
also on the rate at which these characteristics change with postnatal age. The emerg-
ing picture is one of a highly dynamic vascular phenotype that changes in concert
with its environment (Longo and Goyal 2013).
As the cerebrovascular smooth muscle cells and vessels are smaller with less
connective tissue (Goyal et al. 2012), commonly the age-related differences in cere-
brovascular contractile mechanisms have been attributed to vascular structural and
functional immaturity (Bevan and Su 1973; Toda 1991). This is the case, particu-
larly as it relates to the relative inability of vessels to constrict with enough force to
prevent propagation of transient arterial blood pressure increases to the microcircu-
lation, i.e., the “hypo-contractile” hypothesis. Alternatively, increased likelihood of
cerebral artery rupture may result from a greater abundance and/or potency of relax-
ant mechanisms in less mature vessels, the “hyper-relaxation” hypothesis (Longo
et al. 1996b; Nauli et al. 2000; Pearce et al. 1991; Pryds 1991). On one hand, reduced
tone and contractility of cerebral arteries may be appropriate for the relatively low
perfusion pressures typical of fetal life in utero. On the other hand, we know little
of how this may be a consequence of important differences from the adult in relation
to the fine structure and vascular reactivity, as well as differences in patterns of
stimuli received. Unfortunately, little is known about the basis of this vulnerability
in terms of cerebrovascular structure and function.
In perspective, major differences in cerebrovascular relaxation/contraction
mechanisms in the fetus and newborn, as opposed to the adult, are the degree to
which specific elements and signal transduction pathways and their interactions dif-
fer as a function of developmental age. Clearly, important differences in the manner
in which these mechanisms function distinguish the developing cerebral vascula-
ture from that of the adult. Thus, one might be tempted to ask, are these develop-
mental changes merely an epiphenomenon or are they of fundamental biologic
significance. Considered from one point of view, cerebral artery relaxation and
248 12 Some Aspects of the Developing Brain and Nervous System

contraction mechanisms in the fetal and newborn organism work amazingly well.
Nonetheless, the significant differences in mechanistic coupling and interaction may be
a key factor in the vulnerability of the cerebral vasculature to dysregulation in response
to hydrostatic pressure surges, hypoxia and other stress (Longo and Goyal 2013).
That elements of the cerebral artery agonist-mediated, presynaptic and postsyn-
aptic, relaxation and contraction mechanisms should be regulated independently
and show differing responses during the course of maturation should come as no
surprise. This only furthers the view that homeostatic responses differ in the imma-
ture as opposed to the more mature animal. These include the structural transition
from immature “synthetic” to the more mature “contractile” SMC phenotype,
accompanied by major structural changes of essentially every element. For develop-
ing cerebral arteries, the character of many of the responses are similar to those of
the adult, with the trend that the magnitudes of changes are smaller for contractility
and larger for changes in receptor density. Maturation of many of the SMC mecha-
nisms also illustrates the concept of “developmental plasticity.” Overall, multiple
mechanisms are recruited in response to normal development, both to promote
relaxation (hyper-relaxation hypothesis) and to attenuate contraction (hypo-
contractile hypothesis). Within this framework, the multiple independent mecha-
nisms are heterologous and unique for each signal transduction pathway. A caveat
of most of these studies is that a limited number of age groups were examined, e.g.,
preterm fetus, term fetus, newborn, and adult. Thus, the true developmental profiles
of variable changes with maturation are either unknown or poorly described.
Nonetheless, it is the late fetal and newborn period, that phase upon which most
studies have focused, that has high relevance to dysregulation and disease.
In light of the above, one might ask what do the present findings mean for future
research. A number of major challenges lie ahead. Biocomplexity poses perhaps the
greatest challenge, to understand the manner in which cell and tissue functions
emerge from the interactions within the manifold array of cellular, biochemical, and
molecular networks. During recent years, linear models of signal transduction have
provided useful information on the role of various receptors, second messengers,
enzymes, and other cascade elements in terms of development of cerebrovascular
function and dynamics. Nonetheless, as we progress a more encompassing network
model incorporating interactions among a host of molecules will be required to
understand the emergent properties of activity and function of the diverse cerebro-
vascular cells. Thus, in our effort to unravel the underlying basis of biocomplexity
we must move beyond the phenomenology of signaling pathways, to consider their
interactions, feedback mechanisms, and temporal regulation in health as well as
disease (Ingber 1997, 2003a, b). In terms of development, an important lesson is the
plasticity of signal transduction mechanisms in a given cell type and/or vessel. This
suggests that continued exploration of these regulatory mechanisms is likely to be
rewarded with unexpected, important new findings and insights. Although the gen-
eral principles of signaling are becoming clarified, a challenge is to elucidate the
details of the regulatory mechanisms of information flow, signal amplification,
feedback regulation, and crosstalk among different pathways.
References 249

In terms of CBF dysregulation in the fetus and newborn infant, many factors
have profound implications as the basis of hypo- and hyper-reactivity, vessel rupture,
intraventricular hemorrhage, and long-term neurological sequelae. In addition and
of consequence, these studies have implications for the developmental “program-
ming” during fetal and neonatal life of cerebrovascular, cardiovascular, and other
disease in the adult. Thus, one must ask, what do these findings mean in terms of the
clinical care of premature and other newborn infants and other patients? Hopefully,
this synthesis will have vital implications for diagnosis and potential therapy of
those infants with dysregulation of CBF, as well as relevance to the broad field of
preventive medicine and public health. Recent advances are promising in that they
point the direction for moving beyond descriptive phenomenology to investigation
of fundamental cellular and molecular regulatory mechanisms, and understanding
in a deeper sense. Of unprecedented opportunity and great promise, the rapidly
growing diversity and power of new investigative tools and technology offer the
opportunity for further insights into the role of development in regulation of the
cerebrovasculature. Hopefully, a new generation of studies of gene regulation, pro-
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will add to, and stimulate further, rapid advancement in this field of critical impor-
tance. The translational application of this knowledge to the prevention and amelio-
ration of cerebrovascular complications in the fetus and newborn infant constitutes
one of our greatest challenges for the future (Longo and Goyal 2013).

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Chapter 13
Related Developments in Fetal and Neonatal
Endocrinology

As noted above, the second half of the twentieth century saw a virtual explosion of
research in fetal and neonatal physiology. In the UK, to a great extent this was a
result of the work of the Dawes group at the Nuffield Institute, and also to investiga-
tors at Cambridge University. In Australia, this was a consequence of development
of the focal groups in Melbourne, Adelaide and Sydney, and in Canada, develop-
ments at London and Toronto in Ontario. Without question, Dawes and the Nuffield
Institute “school” must be credited with the diaspora of gifted investigators who
migrated to academic institutions in these and other countries. Advances proceeded
in essentially every aspect of developmental physiology and biochemistry. With the
education of talented pediatricians and obstetrician gynecologists committed to
improve the health and well-being of their patients, increasingly “translational” and
clinical research was included. Thus, it is perhaps appropriate to consider some
highlights of these contributions, such as those in reproductive endocrinology,
growth and metabolism, nutrition, neurodevelopment, cardiovascular, pulmonary
and renal function, immunology, and so forth. In each of these areas discerning
clinicians and basic scientists have collaborated to apply theory to the evaluation
and management of major diseases that result in morbidity and mortality. As a
caveat, it must be appreciated that the synopses that follow are not in any sense
exhaustive or complete. The goal here is to give a taste of some of the exciting
developments during this period, in the application to discoveries in basic physiol-
ogy/endocrinology, and their contributions to and implications for perinatal and
neonatal medicine (With the citations provided, the interested reader can pursue
these topics further).

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 257
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_13, © American Physiological Society 2013
258 13 Related Developments in Fetal and Neonatal Endocrinology

Fig. 13.1 (a) Francis H.A. Marshall. (b) Sir John Robert Vane (1927–2004)

13.1 The Beginnings of Reproductive Endocrinology

and Medicine

The early twentieth century saw the emergence of endocrinology and reproductive
medicine. Ernest Henry Starling (1866–1927) had coined the term “hormone,” and
with William Maddock Bayliss (later Sir William; 1860–1924) developed the the-
ory of endocrine control of internal secretions (Bayliss and Starling 1904; Starling
1905). Experiments quickly established the vital role of the pituitary in orchestrat-
ing the functions of other glands and tissues (Crowe 1910; Cushing 1910; Houssay
and Biasotti 1930), including the role of the adenohypophysis in the regulation of
growth (Evans and Long 1921). Other studies demonstrated the ovarian dependence
of the menstrual cycle, that experimental hypophysectomy profoundly affected the
reproductive system, and the oxytocic action of posterior pituitary hormone (Dale
1909). Additional contributions to reproductive endocrinology at this time included
the first definite description of the cyclic changes in the endometrium with the men-
strual cycle and the attribution of pregnancy-induced changes in the mammary
glands to hormones derived from the developing fetus and placenta.
In terms of biologic and physiologic development, one may consider two com-
plementary threads, the differentiation of structure and the integration of function.
Rather than being separate abstractions, these are aspects of a unitary process. Early
in the century, the various embryological contributions and other discoveries were
placed in perspective by Francis H. A. Marshall (Fig. 13.1a) of the Universities of
Edinburgh and Cambridge in his The physiology of reproduction (Marshall 1910).
13.1 The Beginnings of Reproductive Endocrinology and Medicine 259

In this encyclopedic synthesis, Marshall reviewed existing knowledge in reproduc-

tion in its broadest sense, including reference to over 1,000 works. In the preface, he
presented the caveat, “It may be objected that, for a book on physiology, too much
space is devoted to the morphological side of the subject. This has been done pur-
posely, since it seemed impossible to deal adequately with the physiological signifi-
cance of the various sexual processes without describing the anatomical changes
which these processes involve” (Marshall 1910, p. 2). Focused chiefly on reproduc-
tive biology, Marshall presented insights to endocrinology such as that the existence
and respective roles of follicular and luteal hormones were essential to ovulation
(long before either was isolated). With consideration of embryology, placental
development, and related topics, importantly these volumes contributed to the sci-
ence that allowed the genesis of fetal and neonatal physiology. Quickly appreciated
as a masterpiece, a second edition of Marshall’s magnum opus was called for, which
appeared in 1922 following the “Great War,” and included chapters on the new field
of biochemistry of the ovary and the testicle (Marshall 1922). In the introduction to
his 1936 Croonian Lecture “Sexual periodicity and the causes which determine it”
Marshall observed,
… the great majority of animals, both vertebrate and invertebrate, not to mention plants,
have a more or less definite season of the year at which they breed … There is no month of
the year at which some species does not have its breeding season, and yet for the particular
species in question the season is most regular …. In view of the general correlation between
the seasonal and the sexual cycles it must be assumed that these stand in the relation of
cause to effect.
(Marshall 1936, p. 423)

Marshall’s postulate led to a number of fundamental questions regarding mecha-

nisms of animal breeding and reproductive physiology (Marshall and Hammond
1946). As Sir Alan Sterling Parkes (1900–1990) noted in his obituary of Marshall,
Scientists are of many kinds, but inspiration flows most fruitfully from those who are able,
by some gift withheld from lesser men, to divine the richness of uncharted country and sense
the vital landmarks. Thus do they avoid the barren places and the morasses of unimportant
detail which engulf so many. To these, discovery is an art rather than a science, a matter of
instinct rather than of intellectual machinery. Such was Marshall.
(Parkes 1950, p. 248)

In reproductive endocrinology, the late 1920s and the 1930s were a time of fer-
ment. Selmar Aschheim (1878–1965) and Bernhard Zondek (1891–1966) had
announced their test for the diagnosis of pregnancy (Aschheim and Zondek 1928),
and also had isolated pituitary gonadotrophic hormone (Zondek and Aschheim
1927, 1928). Steroid hormones also were under active investigation. Edgar Allen
(1892–1943) and Edward Adelbert Doisy (1893–1986) isolated estrogen (Allen and
Doisy 1923), and George W. Corner and Willard Myron Allen (1904–1993) discov-
ered progesterone (Corner and Allen 1929), Guy Frederick Marrian (1904–1981)
isolated both pregnanediol and estriol (Marrian 1929, 1930), and Adolf Frederick
Johann Butenandt (1903–1995) crystallized both progesterone (Butenandt 1934)
and androsterone (Butenandt 1931). Butenandt and Doisy would win Nobel Prizes
for their fundamental contributions (1939 and 1943, respectively). With these and
260 13 Related Developments in Fetal and Neonatal Endocrinology

other advances, a third edition of Marshall’s Physiology of Reproduction was

planned. However, because of World War II the greatly enlarged (three volume)
multiauthored edition, edited by Sir Alan did not appear until 1952 (Parkes 1952–
1966; also see Parkes 1950; Polge 2006).

13.2 Fetal–Neonatal Endocrinology

A critical issue in developmental physiology in regard to the regulation of growth of

the fetus and its placenta, is that of the role of hormones in this growth and specialized
tissue and organ function, and the extent to which these hormones derive from the
mother, the placenta, and/or the fetus per se and the extent to which they are interac-
tive. In mid-century, Alfred Jost (1916–1991) of Paris demonstrated, in embryonic
rabbits, that decapitation had little or no effect on growth of their trunk or limbs (Jost
1947). Thus, somewhat surprisingly, somatic growth and development including the
cardiovascular, respiratory, and other systems was demonstrated to proceed indepen-
dently of pituitary growth hormones or input from the central nervous system. In an
effort to understand these regulatory mechanisms, in rabbits and rats, Jost performed
a number of studies on the effects of removal of specific organs including the hypo-
thalamus, thyroid, parathyroid glands, and testis on fetal growth and the development
of other organ systems (Jost 1961, 1966, 1968, 1969; Macnaughton 1969).
In large part, the concept of the placenta and fetus, in concert with the mother,
consisting of a “maternal-placental-fetal unit” for hormonal synthesis and metabo-
lism derived from the work of Egon Diczfalusy and his collaborators. In the case of
steroid biosynthesis, by aromatization the placenta converts fetal 16α-hydroxy dehy-
droepiandrosterone sulfate into estriol. This then is secreted into the maternal circu-
lation, and is the main estrogen metabolite excreted in the mother’s urine. The fetus
also can initiate the pathways for conversion of cholesterol to pregnenolone and on
to dehydroepiandrosterone sulfate. Thus, the placenta, in concert with several fetal
organs, plays a unique role in the regulation of steroid hormone production in preg-
nancy (Diczfalusy 1964). Shortly following his graduation from medical school in
Hungary (1949), Diczfalusy moved to Stockholm, Sweden, where his investigations
centered upon the metabolism of steroids in the fetus and placenta, their interconver-
sion, and functional roles (Diczfalusy 1962, 1970, 1974; Mathur et al. 1970). He rose
to become professor and head of the Reproductive Endocrinology Research Unit at
the Karolinska Institute. Unique in the study of fetal physiology, these historic
studies were conducted in the fetuses of women having elective termination of preg-
nancy. Although raising ethical considerations regarding human experimentation
and fetal research (see below), one must remember that these studies were performed
under strict guidelines of the Medical Research Council of Sweden. With the work
of Jost and others, these studies marked the beginning of the discipline of endocri-
nology of the “maternal-placental-fetal unit” (Klopper and Diczfalusy 1969).
A related contribution of vital importance to the reproductive sciences was
the discovery of the prostaglandins. In 1934, Ulf Svante Hansson von Euler
13.2 Fetal–Neonatal Endocrinology 261

(1905–1983) first reported that the lipid fraction of human seminal fluid, which he
called prostaglandin, possessed potent contractile activity of smooth muscle (Euler
1934). Three decades later, Sune Karl Bergström (1916–2004) with Bengt Ingemar
Samuelsson and colleagues determined the chemical structure of several of the
specific prostaglandin molecules (Bergström et al. 1962, 1964; Bergström and
Sjövall 1960).
Critical to the elucidation of many aspects of the pharmacology and metabolism
of eicosanoids, are the contributions of Sir John Vane (Fig. 13.1b), who in 1953
earned his doctoral degree in pharmacology with Dawes at the Nuffield Institute. A
graduate of the University of Birmingham, Vane majored in chemistry at a time in
which the stress was on chemical synthesis rather than experimentation. During a
career advisory session, his Professor of Chemistry asked him about his plans follow-
ing graduation. Vane, who at this time was rather disillusioned about the field,
responded “Anything but chemistry” (Moncada 2006, p. 403). For his doctoral stud-
ies in pharmacology at Oxford, he worked with Professor Joshua Burn, the head of
that department, and with Dawes with whom he published two manuscripts in the
Journal of Physiology (Dawes and Vane 1956; Dawes et al. 1953). Following a post-
doctoral fellowship at Yale, he joined the Institute of Basic Medical Sciences located
in the Royal College of Surgeons complex across from Lincoln’s Inn Fields. Here,
during the late 1950s and the 1960s he developed the blood-bathed superfusion bio-
assay that has proven so valuable (Vane 1964). In this sensitive bioassay, the proper-
ties of minute amounts of biological chemicals can be analyzed, allowing
determination of the manner in which vasoactive substances are handled in the circu-
lation (Moncada 2006; Vane 1964, 1969). One of Vane’s key discoveries was that
angiotensin I is converted to angiotensin II on passage through the pulmonary circu-
lation, rather than forming in the plasma as had been assumed (Bakhle et al. 1969).
Not long thereafter, it was established that angiotensin converting enzyme (ACE) is
localized at the luminal surface of pulmonary endothelial cells (Ryan et al. 1975).
(With about one-half of the vascular endothelial cells residing in the lung, it is per-
haps not surprising that that organ serves metabolic functions). In the mid-1960s, a
Brazilian pharmacologist, Sergio Ferreira joined Vane as a postdoctoral fellow. With
him he carried a vial of the dried extract of the venom of an Amazon viper (Bothrops
jararaca) to study its properties, which he had shown potentiates the actions of bra-
dykinin. Following other studies Ferreira, Vane, and colleagues determined that the
venom contained an inhibitor of the angiotensin-converting enzyme (Aiken and Vane
1970; Ferreira 2000; Greene et al. 1972). This work led to the discovery of Serpasil,
the first ACE inhibitor used in the treatment of hypertension. By the early 1970s, the
“Vane cascade bioassay” was used by many investigators. Subsequently, Vane also
elucidated the mechanism by which nonsteroidal anti-inflammatory agents such as
aspirin (acetylsalicylic acid) inhibited prostaglandins synthesis (Ferreira and Vane
1979; Vane 1971, 2002).
In 1973, Vane moved to the Wellcome Foundation to become Director of
Research and development. In studies of anaphylaxis in guinea pigs, in addition to
the release of prostaglandin E2 and F2α, with collaborators he discovered a third
compound they named PGX. This was quite unstable, had potent vasodilatory
262 13 Related Developments in Fetal and Neonatal Endocrinology

activity, and inhibited platelet aggregation (Bunting et al. 1976; Moncada et al.
1976). This they soon named prostacyclin (PGI2), a major product of arachidonic
acid metabolism (Moncada and Vane 1979). The physiologic properties and ubiqui-
tous nature of prostaglandins displayed balance, such as between the constrictor
activity of thromboxane A2 formation by platelets and prostacyclin production by
the vascular wall (Bunting et al. 1983).
In 1986, Sir John moved to the William Harvey Research Institute, which he
established at St. Bartholomews Hospital Medical College. There, he focused on
elucidating selective inhibitors of cyclooxygenase 2 (COX-2) and the interplay
between nitric oxide and endothelin in the regulation of vascular function (Moncada
2006; Vane et al. 1994). Discovery of the important role of these compounds in the
regulation of a number of biological functions, including health and disease, opened
the whole field of prostaglandin research with its great impact in reproductive phys-
iology (Vane 1982; Vane and Bergström 1979). These contributions were followed
by the award of the 1982 Nobel Prize in Physiology or Medicine to Bergström,
Samuelsson, and Vane.
In his essay “My life and times …,” Sir John reviewed many aspects of these
studies. He concluded,
My life and times with enzymes and mediators have been a fascinating detective story; find-
ing previously undiscovered pathways and interactions that have led to important new con-
cepts and drugs. I want to thank all those colleagues, PhD students, technicians and postdocs
who have contributed to the excitement of my research ….
(Vane 2001, p. 797)

Of Sir John Vane, Sir Salvador Moncada, of the University College London has
written,
John was an ingenious, hands-on pharmacologist, able to generate meaningful hypotheses
almost effortlessly. He was a gifted speaker and writer, a motivator and a teacher to several
generations of pharmacologists. He had a great understanding of biological processes and a
keen eye for the behavior of the tissues in his beloved bioassay. One of his favourite phrases
to students reporting back to him with results that they did not understand was ‘the tissues
never lie’—it is the interpretation that can fail.
(Moncada 2006, p. 409)

Gautam Chaudhuri, a doctoral student of Vane in the 1970s, and now at the
University of California Los Angeles, has written,
Many of us who were mentored by Sir John were trained as classical pharmacologists.
While Professor Dawes was pursuing fetal physiology, Sir John focused on vasoactive sub-
stances. This was not surprising as mentors and mentees do seem to part as time progresses.
Professor Vane was a brilliant scientist and went on to train numerous individuals who have
and continue to occupy high positions in academia. In addition, many individuals who
worked in his lab as visiting scientists also have received wide recognition.
While pursuing my Ph.D., I was lucky to come in contact with illustrious people who
also considered Sir John a mentor and friend. These included Professor Sir Salvador
Moncada, currently of the University College, London. Sir John’s students and collabora-
tors have done exceedingly well: Professor Moncada was elected as a Fellow of the Royal
Society of London and is also a Foreign Associate of the National Academy of Sciences,
USA. Sergio Ferreira was also elected as a Foreign Associate of the National Academy of
13.2 Fetal–Neonatal Endocrinology 263

Fig. 13.2 (a) Geoffrey W. Harris (1913–1971). (b) Geoffrey D. Thorburn (1930–1996). (c)
Frederick Naftolin and John R. G. Challis (ca. 1970). (d) Sir Graham “Mont” Liggins
(1926–2010)

Sciences, USA. Another student of his, Roderick Flower, who completed his PhD under his
mentorship, was elected to the Royal Society. This all emphasizes the role of Geoffrey
Dawes in training a unique individual who won the Nobel Prize, and also trained other
illustrious scientists.
(Letter from GC to LDL, 20 July 2012)

From the 1960s to the present, the field of developmental endocrinology has
virtually exploded, with increased understanding of the role of glucocorticoids, the
insulin-like growth factors-1 and -2 (IGF-1, IGF-2), and other hormones and mito-
genic peptides in the regulation of growth and development. One who contributed
greatly to this field was Geoffrey Donald Thorburn (1930–1996) (Fig 13.2b), a
graduate in medicine from the University of Sydney (1956). In the mid-1970s,
Thorburn spent 5 years at the Nuffield Institute, before returning to Australia to
head the Department of Physiology at Monash University. Particularly important
contributions were those relating to the hormonal regulation of parturition (Bassett
and Thorburn 1969; Bassett et al. 1969; Thorburn and Challis 1979), including the
major role of prostanoid production by the placenta in this regard (Rice and
Thorburn 1989; Thorburn 1991). Many aspects of Thorburn’s investigative studies
have been reviewed (Jenkin et al. 2009). A long-time colleague of Thorburn, who
264 13 Related Developments in Fetal and Neonatal Endocrinology

continued to pursue an understanding of the hormonal regulation of parturition and

other aspects of developmental endocrinology was John R. G. Challis (Fig 13.2c),
most recently with the Michael Smith Foundation for Health Research, Vancouver,
British Columbia and who generously prepared the Foreword for this volume
(Challis and Brooks 1989; Challis et al. 2000; Thorburn and Challis 1979).
At Cambridge University, Robert Semple Comline (1920–1998) with his colleague
Marian Silver (1928–1994) continued in the Barcroft–Needham–Hammond–
McCance–Widdowson tradition of pursuing several facets of fetal–neonatal growth
and development and endocrinology. Particular contributions included that of function
of the developing adrenal gland in fetal homeostasis (Blaschko et al. 1967; Comline
et al. 1965; Comline and Silver 1961, 1966). In addition to the lamb (Comline and
Silver 1972; Fowden et al. 1989), the Cambridge group studied comparative metabo-
lism in several developing species including the cow (Balfour and Comline 1962;
Blaschko et al. 1967; Comline and Silver 1976; Comline et al. 1974), horse (Fowden
et al. 1980, 1984), and pig (Comline et al. 1979; Silver et al. 1986, 1988).

13.3 Developmental Neuroendocrinology

Notable in regard to neuroendocrine aspects of brain development, was the work of

Geoffrey Wingfield Harris (1913–1971) (Fig. 13.2a). After working at Cambridge
under F.H.A. Marshall, Harris qualified in Medicine at St. Mary’s Hospital, London
(1939), and then returned to Cambridge University. Still later, he held the Fitzmary
Chair of Physiology at the University of London (1952). Commencing in 1962, he
served as Dr. Lee’s Professor of Anatomy at Oxford University. With a singular pas-
sion, Harris recognized and pursued the relation of the hypothalamus to the pituitary
gland in regulation of the gonadotrophins. He was the first to appreciate the role of
the hypophyseal-pituitary portal circulation as the highway by which endocrine
messages produced by the hypothalamus reached the anterior pituitary gonado-
trophs. Harris termed this material “luteinizing hormone releasing factor,” later
called gonadotrophin releasing hormone, GnRH. His studies laid the foundation for
reinvention of the hypothalamus as an active partner with the anterior pituitary in
vital aspects of endocrinology, especially the reproductive sciences. This concept
that the brain regulates the neuroendocrine system by a remarkably orchestrated
pattern of synthesis and secretion of a family of peptide hormones has been
described by numerous workers in the field (De Groot and Harris 1952; Donovan
and Harris 1972; Harris 1948, 1952, 1955, 1961, 1964a, b, 1970, 1972; Harris and
Campbell 1966; Harris and Donovan 1966; Harris and Jacobsohn 1952a, b; Harris
and Levine 1965; Naftolin et al. 1971a, 2007; Raisman 1997; Reichlin 1964; Vogt
1972).
Frederick Naftolin (Fig 13.2c), currently Director of Reproductive Biology
Research and Codirector of the Interdisciplinary Program in Menopause Medicine
at New York University, worked with Harris from 1968 to 1970. He recalls,
13.3 Developmental Neuroendocrinology 265

While [Geoffrey] Dawes was making his observations on the cardio-respiratory side, there
was ferment in South Parks Road about the sexually determined development of the regula-
tion of gonadotrophins. Years before, Geoffrey Harris and collaborators had refined the
work of [Carroll Athey] Pfeiffer (Pfeiffer 1936) and others to identify the role of the hypo-
thalamus, rather than the pituitary, in gender-specific gonadotrophin regulation. (Harris
1964a; Harris and Levine 1965) We worked to further this body of evidence. This was the
time when objective, sensitive, precise and practical hormonal measurements were becom-
ing available. Since I had worked on an assay for human LH [luteinizing hormone] as an
endocrinology fellow with Charles Alvin Paulsen (1924–2008), my D.Phil thesis project
was to develop and apply an immunoassay for rat LH.
The laboratory worked mainly on rats, though we occasionally studied rabbits and
humans. Rats are born during the period of sexual differentiation of the regulation of gonad-
otrophin regulation. The developmental window is open from a couple of days before par-
turition until the end of the first 2 weeks of life (MacLusky and Naftolin 1981). During this
… “critical period,” the hypothalamic circuitry for gonal hormonal suppression (estrogen)
of GnRH (negative feedback), followed by disinhibition of GnRH release by the preovula-
tory surge of circulating estradiol (positive feedback), or for blocking the surge, is laid
down in the rat hypothalamus. Females have both negative- and positive-feedback regula-
tion of gonadotrophin secretion, while males have only negative feedback regulation.
Females exhibit positive feedback and this is the default circuitry of the hypothalamus. This
developmental sexual dichotomy is the outcome of a further elaboration of the developmen-
tal program in males that blocks the ability of the hypothalamus to disinhibit GnRH secre-
tion, as in positive feedback. This “sexual differentiation of the brain” is caused by exposure
to testosterone from the testis during this perinatal period (Harris and Naftolin 1970;
MacLusky and Naftolin 1981). The timing of the “critical period” for brain sexual differen-
tiation is species-dependent and usually between E15 and P15. Conveniently, rats are born
at E21–22, so there is a window of opportunity to study experimentally the mechanism of
the testes’ effect on their brain sexual differentiation in rats that extends from E ~17 to P
~14 (MacLusky and Naftolin 1981). Studies administering sex steroids rather than minced
testis showed that testosterone or its metabolites will masculinize the rat’s regulation of
gonadotrophins as an adult irrespective of the genetic sex (Jaggard and Bradbury 1961).
But, while testosterone may be secreted from the testis, the molecular mechanism of its
action was not known. This was especially true since evidence had also been reported indi-
cating that natural and synthetic estrogens and partially aromatized androgens also could
masculinize the genetic female rat’s control of gonadotrophins (MacLusky and Naftolin
1981). So, at the end of the 1960s the active agent at the level of the brain’s cells remained
unresolved (Naftolin 2012).
The occurrence of the critical period at the time of parturition and thereafter in rodents
is a boon to experimental testing and treatment; the work had progressed to the point of
requiring blood hormone measurements to measure the results of manipulating the system.
Charles S. Corker and I were the two graduate students tasked with this job. Corker and his
supervisor, Donald Exley solved the measure of estradiol in the circulation by the novel use
of sex hormone binding globulin (SHBG) to bind pictogram amounts of estradiol in the
plasma to measure the competition of endogenous estradiol for radio-labelled estradiol
(Corker et al. 1970). I utilized the cross-reaction of rat luteinizing hormone (LH) with anti-
human chorionic gonadotrophin to develop a radioimmunoassay to measure rat LH
(Naftolin 1970). The combination allowed the first concurrent measures of blood estradiol
and LH, and showed conclusively that the estrogen surge preceded the LH peak in humans
and rodents (Brown-Grant et al. 1970; Corker et al. 1969; Harris and Naftolin 1970). Under
the direction of Keith Brown-Grant we then turned our attention to brain sexual differentia-
tion of gonadotrophin secretion.
The pioneering work by Pfeiffer showed that the organization of the central axis that
silences positive feedback in rats arises from the testis, and this effect occurs during the
266 13 Related Developments in Fetal and Neonatal Endocrinology

perinatal period in genetic males and females. The presence of the ovary is of no moment in
this aspect of development (Pfeiffer 1936). Parenthetically, Pfeiffer thought that this effect
was at the level of the adenohypophysis. He later confided to me that this bias was the result
of the enormous influence at the time of Harvey Cushing and his preoccupation with the
pituitary as the main controlling influence over the regulation of endocrine function (Pfeiffer,
personal communication). However, Harris and Jacobsohn showed definitively that the orga-
nization of positive feedback and its expurgation by the testis is independent of the pituitary;
the location of sexual differentiation is in the hypothalamus (Harris and Jacobsohn 1950).
That this regulation by the hypothalamus was due to the intactness of the pituitary-portal
system was the subject of an acrimonious and public debate between Harris and the Queen’s
physician, Sir Solly Zuckerman (1904–1993) (Thomson and Zuckerman 1955). Harris was
ultimately proven correct and [in Zuckerman’s review of Harris’ monograph Neural control
of the pituitary gland (Harris 1955)] received a qualified admission (Zuckerman 1956).
Harris had this framed and hung in his office. Nonetheless, Zuckerman continued to bitterly
deride Harris’ work, which could have played a role in Harris not receiving the Nobel Prize.
In 1977, the Prize was awarded to Andrew Viktor Schally and Roger Charles Louis Guillemin
[which they shared with Rosalyn Sussman Yalow (1921–2011)] for the discovery of the
chemical makeup of the hypothalamic releasing hormones. [Prior to receiving the Nobel
Prize, Guillemin had been awarded the National Medal of Science (1976) by President
Gerald Rudolph Ford (1913–2006; President 1974–1977)]. Fortunately, Professor Harris
lived to relish his victory over Zuckerman, and this was the subject of conversations over our
evening sherry in his office. Sadly, Zuckerman continued to incorrectly disclaim Harris’ hav-
ing proven that the portal blood mainly flows from the hypothalamus to the pituitary, and not
the other way around, even after Harris’ death. This scurrilous behavior caused me to walk
out during a lecture he gave at the Oregon Primate Center.
As the GnRH neurons that secrete into the portal vessels are located in the hypothala-
mus and are targeted by hypothalamic neurons, brain sexual differentiation occurs in this
area of the brain (Harris and Naftolin 1970; MacLusky and Naftolin 1981). Working with
Keith Brown-Grant and Allan U. Munck, another visitor to the Department, we tested and
found wanting the idea that testosterone was organizing the male rat brain via formation of
ring A-reduced products (Brown-Grant et al. 1971). This opened the way for the ultimate
testing and proof that male rats converted the testosterone from the fetal-newborn testis to
estrogen that organized the hypothalamic circuitry for monotonic control of the gonadotro-
phins. This formulation depended on the proof that the brain could convert androgen to
estrogen, and was accomplished working with Kenneth John Ryan (1926–2002) [at the
University of California, San Diego] shortly after I completed my training at Oxford
(Naftolin et al. 1971a, 1975). We studied dissected hypothalamic tissue from mid-trimester
female and male fetuses. Promptly after delivery of fetuses that had been terminated by
saline infusion into the amniotic sac it was determined that there were no signs of life and
the brain was removed and bloc-dissected to furnish the anterior and posterior hypothala-
mus. I included the temporal lobe as a putative negative control. The method of proving the
presence of aromatization in the tissue was the same as the Ryan lab had been using to study
placental aromatization of androgens. This is a method based on incubation of the homog-
enized tissue with radio-labelled androgen (14C-androstenedione) and performing a pheno-
lic extraction to isolate the estrogens. The extract then is treated to form phenolic conjugates,
acetates in this case, which are then extracted and recrystalized to constant specific activity.
The products are compared with authentic estrogen acetates to prove that newly formed
estrogen has been made by the microsomes in the brain homogenates (Naftolin et al. 1971a, b).
The proof of the presence of aromatase in neurons was substantiated by the discovery of
aromatase in synaptosomes for rat brain. While not yet explained, this finding is challeng-
ing as it implies additional effects of aromatase in the brain other than as would result solely
from the production of estrogen. We have commented on the interesting possibilities and
hope someday to discover the true meaning of this interesting finding (Naftolin et al. 1996).
13.4 Hormonal Regulation of the Timing of Birth 267

The discovery of aromatization by brain cells was a byproduct of studies begun in

Oxford on brain sexual differentiation that led to the “Aromatization Hypothesis.” The dem-
onstration of this novel biology led to important changes in the understanding of brain
metabolism and action. There remain many unexplained ramifications of this work (Naftolin
et al. 2007; Panzica et al. 2012). Regardless, the discovery that set them off would not have
been possible without the support of many seasoned scientists for a naïve young academic
(Naftolin 2012).
Other Oxford by-products of [Harris’] interest in understanding the fetal–neonatal
development of control of the gonadotrophins included observation of the pulsatile release
of LH in humans (Naftolin et al. 1971a, b), and evidence that male rams are seasonal breed-
ers with low LH in the off-season. This work also included the first observation of the pul-
satile nature of LH secretion (Katongole et al. 1971). Since Professor Harris was the person
who in 1936 had postulated that the hypothalamus secreted factors into the pituitary-portal
vessels that arrived at the adenohypophyseal cells and released the pituitary trophins (Harris
and Naftolin 1970), our work at the Department of Human Anatomy included testing puri-
fied sheep luteinizing hormone releasing factor (LRF) on human subjects and show that it
induced LH secretion (Naftolin et al. 1971a). Harris was elated with these studies, but could
not proceed with the sequencing of the molecule because his biochemist collaborator, the
Imperial Chemical Industries’ ace chemist Harry Gregory, was occupied with … bradyki-
nin [which had been discovered earlier (Rocha E Silva et al. 1949)]. Later, after Professor
Harris’ premature death the actual sequence of thyrotrophin releasing factor and LRF were
determined and the peptides could be re-named releasing hormones. The determination of
the chemical structure of releasing hormones contributed to the 1977 Nobel Prize [being]
awarded to Guillemin and Schally. It was very sad that Harris could not have shared the
medal that he so richly deserved.
The time spent in Oxford branded not only my professional identity; it indelibly laid an
experimentalist’s circuitry in my brain. Inspired by Harris, we followed the discovery that
formation of estrogen by the brain furnished the mechanism of testosterone’s organization
of the male rodent brain’s gonadotrophin release pattern (Naftolin et al. 1972b; MacLusky
and Naftolin 1981), with exposition of the effect of estrogen on developing hypothalamic
neurons and circuitry (Nilsen et al. 2000), and the cellular mechanisms by which the hypo-
thalamus undergoes synaptic plasticity and the midcycle release of LH to trigger ovulation
(Naftolin et al. 2007).
The work on fetal brain neuroendocrine development and function that Professor Harris,
Keith Brown-Grant, and others accomplished in Oxford during [the] same period that
Dawes was exploring fetal-neonatal cardio-pulmonary development and function was little
known to the other side. However, it can now be seen as an important companion chapter in
the Oxford contribution to developmental neuroendocrinology.
(Naftolin 2012; Letter from FN to LDL, 28 December 2009)

13.4 Hormonal Regulation of the Timing of Birth

A clear and overwhelming contribution to research during the past half-century is

understanding that the timing of birth is a complex, multifactorial process of inter-
related biologic mechanisms. The idea that the human fetus plays a role in the initia-
tion of parturition had long been implied by the clinical observation of prolonged
pregnancy in cases of anencephaly of the developing fetus. For instance, in 1933
from the Women’s and Maternity Hospitals, University of Liverpool, Percy Malpas
268 13 Related Developments in Fetal and Neonatal Endocrinology

(1901–1980) reported that in 9 of 44 cases (20 %) of anencephaly, pregnancy was

unduly prolonged, as it was also in three cases each of hydrocephalus and spina
bifida. In several of the anencephalic infants, the pituitary gland as well as the adre-
nal glands were absent (Malpas 1933). Others reported similar findings (Comerford
1965; Rea 1898). In animals, several lines of evidence also support this concept. For
instance, greatly prolonged gestation occurs in Guernsey (Kennedy et al. 1957), and
Holstein-Friesian (Holm et al. 1961; Jasper 1950) cattle, in which the fetus demon-
strated central nervous system anomalies including aplasia of the anterior pituitary
gland, and in some cases adrenal insufficiency. About the same time as these reports
in cattle, facial congenital malformation was recognized in 1–8 % of newborn sheep
whose mothers had pastured in certain alpine meadows in southwestern Idaho. This
anomaly was restricted to the head, and varied from classical cyclops with a single
eye to deformity of the upper jaw. A veterinarian with the US Department of
Agriculture Research Service in Utah, Wayne Binns (1911–1994) and colleagues,
observed that the most severe of these cases were associated with prolonged gesta-
tion. The local ranchers did not believe the condition to be hereditary, but rather that
it resulted from some environmental toxin (Binns et al. 1959) ingested by the ewe
early in gestation (Binns et al. 1960). Soon it was discovered that in those sheep
which had grazed on the plant Veratrum californicum on days 10–15 of gestation,
the period of gestation was markedly prolonged in a manner similar to that described
in cattle. In addition, the fetus demonstrated cyclops with multiple intracerebral
abnormalities including absence of the hypothalamus, and pituitary gland, as well
as hypoplasia of the adrenal glands (Binns et al. 1964).
It was not until the studies of Graham Collingwood Liggins (later Sir Graham;
1926–2010) (Fig. 13.2d) of Auckland, New Zealand, and colleagues, however, that
the essential role of the fetal hypothalamic–pituitary–adrenal axis in the initiation of
parturition was established. An obstetrician gynecologist at the National Women’s
Hospital with a passion for research, Liggins was influenced by a colleague Albert
William Liley (later Sir William; 1929–1983) who had revolutionized the manage-
ment of obstetrical patients with the rhesus hemolytic disease erythroblastosis feta-
lis by intrauterine transfusion of the anemic fetus (Liley 1963) (see below). Tackling
the problem of premature labor “Mont” (for his childhood fascination with Monty
the Mouse) Liggins devised a plan to elucidate the mechanism of the timing of par-
turition on animals. The hope was that this understanding might lead to the preven-
tion of preterm birth. Believing this involved the fetal pituitary gland, using lambs
from a nearby agricultural research station, he taught himself to perform fetal
hypophysectomy (Watts 2010). Then on a sabbatical with Peter Carleton Kennedy
(1923–2006) at the University of California Davis, Liggins electrocoagulated the
pituitary gland of 17 fetal lambs during the last third of gestation (normal term
~147 days). With ablation of 70 % or more of the hypophysis, somatic develop-
ment was retarded, including that of epiphysial centers, with hypoplasia of adrenal
cortex, thyroid gland, and interstitial cells of testis, and other changes, as compared
to controls. These findings demonstrated the critical role of the pituitary gland dur-
ing antenatal, as well as postnatal development (Liggins and Kennedy 1968;
Liggins et al. 1967). Although these fetuses subjected to hypophysectomy were
13.4 Hormonal Regulation of the Timing of Birth 269

alive at delivery, they demonstrated extensive endocrine and metabolic distur-

bances (Liggins and Kennedy 1968).
In a further study of fetuses of 24 pregnant ewes, Liggins, Kennedy, and Louis
W. Holm performed pituitary ablation by electrocoagulation between 93 and 142
days of gestation. Following destruction of 70 % of the pituitary gland or destruc-
tion of the fetal hypothalamus with section of the pituitary stalk, pregnancy was
prolonged to from 158 to 187 days’ gestation (Liggins et al. 1967). In a subsequent
report Liggins also demonstrated the luteolytic role of prostaglandin F2α in sheep
parturition (Liggins and Grieves 1971). A vital contribution, these studies estab-
lished the essential role of the fetal pituitary and adrenal glands, and related hor-
monal changes, in the initiation of parturition (Liggins et al. 1973). As a caveat,
while Liggins and his colleagues were careful to point out differences between the
physiologic and endocrinologic characteristics of the pregnant ewe and the human,
they noted the potential for this experimental model to explore in humans mecha-
nisms of the initiation of labor and, hopefully gain understanding of the premature
onset of labor. Subsequently, a number of studies demonstrated an antepartum rise
in corticosteroids in sheep (Bassett and Thorburn 1969), human (Smith and
Shearman 1974), and other species, with a fall in circulating progesterone levels
(Bassett et al. 1969).
A critical contribution to understanding the hormonal changes associated with
parturition, and the hormonal events of the fetus with those of the mother was that
of John R.G. Challis and Robert Brian Heap and colleagues in the early 1970s. With
the use of a newly developed radioimmunoassay for total estrogen, Challis, still a
doctoral student at Cambridge University, demonstrated in sheep an abrupt and dra-
matic 10- to 20-fold rise in this hormone just before the onset of parturition (Challis
1971). Later, this was shown to be associated with increased output of prostaglandin
F2a from intrauterine tissues (Challis et al. 1972). Subsequently, at Harvard
University, working in the laboratory of Kenneth Ryan, Challis correlated the pre-
partum changes of estrogen in the rabbit with a concomitant fall in progesterone in
both plasma (Challis et al. 1973) and myometrium (Challis et al. 1974a). In pri-
mates, however, it was difficult to demonstrate peripheral plasma changes of pro-
gesterone before birth (Challis et al. 1974a, b), and attention then turned to hormone
levels in the amniotic fluid as a reflection of intrauterine steroid changes (Mitchell
et al. 1976), and to the importance of paracrine processes in the regulation of labor.
In rabbits, they also showed that the progesterone fall was associated with prosta-
glandin F2α-induced luteolysis (Challis et al. 1974c), and that ovarian granulosa
cells produced the prostaglandin (Erickson et al. 1977). Challis’ latter work was
developed at the Nuffield Institute, in collaboration with Geoffrey Thorburn and
Jeffrey Robinson.
Of vital importance to fetal development is well-orchestrated maturation and
interaction of the hypothalamic–pituitary–adrenal axis. Some aspects of this have
been reviewed above. In addition to corticotrophin-releasing hormone (CRH), argi-
nine vasopressin (AVP) was discovered to be an adrenocorticotropic hormone
(ACTH) secretagogue. Although corticotrope stimulation releases ACTH relatively
early in development, the sensitivity of adrenal cortical cells to ACTH appears
270 13 Related Developments in Fetal and Neonatal Endocrinology

relatively late in gestation. Complicating an understanding of this regulation, is the

fact that during the last few weeks of gestation CRH is expressed in large amounts
by the placenta (Gitau et al. 2004; Majzoub and Karalis 1999; Mastorakos and Ilias
2003). Proopiomelanocortin (POMC), the primary precursor of several anterior
pituitary peptides is enzymatically cleaved to yield ACTH1–39 (Bell et al. 2005).
Because in some early studies of ACTH biology the specificity of ACTH1–39 anti-
bodies used were relatively poor; confusion arose as to changes and role of ACTH
in adrenocortical function (see Rose et al. 2011). Clearly, evidence indicates that the
bioactive ACTH1–39 concentration increases near term (but not in proportion to the
large amount of circulating placental-derived CRH (Castro et al. 1992; Lockwood
et al. 1996)), and this correlates with a plasma surge in cortisol (Castro et al. 1992).
In the near-term fetal sheep, the anterior pituitary responsiveness to AVP also
increases strikingly (Fora et al. 1996; Perez et al. 1997). A leading group in these
studies has been that of James Carrington Rose at Wake Forest University (For
review see Rose et al. 2011).
Maturation of the ovine fetal adrenal cortex, with the resultant increase in corti-
sol biosynthesis has been shown to be critical for organ maturation as well as the
timely initiation of labor. Another group that has contributed greatly to an under-
standing of the development of the fetal hypothalamic–pituitary–adrenal axis, and
its role in the initiation of parturition, is that of Elvie Marelyn Wintour and her col-
leagues at the Howard Florey Institute for Experimental Physiology and Medicine
at the University of Melbourne (MacIsaac et al. 1989; Tangalakis et al. 1990;
Wintour 1984; Wintour et al. 1985, 1986). During the last few weeks of gestation,
the ovine fetus demonstrates a progressive increase in corticotrophin releasing hor-
mone (CRH) mRNA in the paraventricular nucleus of the hypothalamus. This is
coupled with an increase in POMC concentration in the pituitary with enhanced
POMC processing during late gestation, resulting in enhanced ACTH secretion (for
review see Challis et al. 2001). Beyond the hypothalamic–pituitary portion of the
axis, critical maturational changes at the level of the adrenal gland also occur in
concert with increases in ACTH (Braems et al. 1998). In the latter part of gestation,
there is an augmentation of adrenal responsiveness to ACTH, mediated not only by
increase ACTH receptor expression, but also by increased ACTH receptor binding
and adenylate cyclase response to ACTH (Durand et al. 1980; Saez et al. 1984;
Tangalakis et al. 1990).
Charles Andrew Ducsay at Loma Linda University with Dean Allen Myers at the
University of Oklahoma have shown that in late gestation, enhanced ACTH signal-
ing contributes to the ontogenic rise of key steroidogenic enzymes such as the cyto-
chrome P450, family II, subfamily A, polypeptide 1 (CYP11A1), and cytochrome
P450 (CYP17) (Myers et al. 2005). These investigators also showed that as term
approaches, maturational changes in the hypothalamic–pituitary–adrenal axis are
responsible for the observed increase in fetal plasma cortisol (Harvey et al. 1993;
Magyar et al. 1981), in part this being regulated by activation of endothelial nitric
oxide synthase (Ducsay and Myers 2011). Of particular note, acclimatization to
13.4 Hormonal Regulation of the Timing of Birth 271

high altitude long-term hypoxia is associated with activation of the HPA axis,
increased expression of adrenal endothelial cell nitric oxide synthase (Monau et al.
2009), with the NO inhibiting ACTH-induced cortisol secretion (Monau et al. 2010,
Vargas et al. 2011). The superimposed stress of more severe hypoxia may overcome
the NO inhibition of steroidogenesis via induction of protein phosphatases and
other factors (Ducsay and Myers 2011), and cortisol excretion is enhanced (Myers
and Ducsay 2012).
In Liggins’ later studies, he demonstrated the effect of ACTH or cortisol infusion
into the sheep fetus in the induction of premature labor. This did not occur following
an infusion of mineralocorticoid. The question remained, from where does the sig-
nal arise that initiates the onset of labor in sheep? Based on data indicating high
concentrations of corticotrophin-releasing hormone in the median eminence of the
hypothalamus, and that innervation of the latter arises in the parvocellular portion
of the paraventricular nucleus Thomas Joseph McDonald (1943–2013) and Peter
William Nathanielsz of Cornell University, Ithaca, NY tested the hypothesis that
elimination of this innervation would result in a significant delay in the onset of
parturition. At 120 ± 2 days gestation, by stereotaxis they placed electrolytic lesions
in the paraventricular nuclei. They also placed small glucocorticoid implants adja-
cent to these nuclei to block further the physiologic ACTH response to hypoxemia
and hypertension (McDonald and Nathanielsz 1991). In the lambs so lesioned, labor
failed to be initiated by 157 dpc, at which time the pregnancy was terminated for
tissue collection. Additionally, lesioned fetuses failed to demonstrate an ACTH
increase in response to severe hypotension (50 % decrease in blood pressure), and
failed to demonstrate the normal near-term increase in circulating ACTH and corti-
sol (McDonald and Nathanielsz 1991). Because the hippocampus has been shown
to modify function of the hypothalamic–pituitary–adrenal axis, in a further study,
McDonald and colleagues stereotaxically transected the dorsal columns of the hip-
pocampal fornix to test this hypothesis. With no effect on fetal hormonal levels or
gestational length, the authors concluded that the lack of hippocampal maturity cre-
ates a lack of negative feedback to allow the preparturient great increase in ACTH
(McDonald et al. 2006).
In addition to his monumental studies on the role of the fetal hypothalamic–
pituitary–adrenal axis in the initiation of labor, Liggins also first established the role
of glucocorticoids in maturation of the lung (Liggins 1969a, b; see below). Liggins
has given an historical account of studies on the onset of labor (Liggins 1988), and
with colleagues reviewed the evidence for the mechanisms of the regulation of
parturition in the human (Liggins et al. 1977). Despite the extent of our knowledge
of the events leading to the timing of parturition in sheep and other ungulates, these
mechanisms and the relative roles of endocrine, paracrine, and other factors, vary
widely among species. It is sobering to appreciate that we still are far from under-
standing these fundamental mechanisms of hypothalamic–pituitary–adrenal and
associated regulation in humans or other primates.
272 13 Related Developments in Fetal and Neonatal Endocrinology

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Chapter 14
Further Developments in Fetal and Neonatal
Physiology

14.1 Pulmonary Physiology and Respiratory Distress

Syndrome

An example of the manner in which discoveries in fundamental physiology and

biochemistry have combined with clinical investigation to impact care of the new-
born infant, perhaps no more striking instance is that of an understanding of the lung
and the changes that occur at birth. Survival at birth depends on the optimal devel-
opment and maturation of the lung in utero. Disorders of lung growth, maturation,
and the regulation of respiration continue to be among the most important problems
with which the neonatologist has to deal. As noted above, in the USA, as well as
throughout the world, premature birth occurs in 7–12 % of pregnancies, a major
complication of which is pulmonary immaturity with resultant respiratory distress
syndrome (RDS). Affecting more than 10 % of infants born prematurely, this poten-
tially devastating condition is characterized by tachypnea, cyanosis, grunting, and
intercostal and subcostal chest wall retractions. It is associated with both short- and
long-term complications such as alveolar rupture with development of pneumotho-
rax, pulmonary interstitial emphysema, and other conditions. In the USA alone
during the 1950s, this condition claimed the lives of more than 10,000 infants a year.
A monumental discovery was that inadequate pulmonary surfactant was associated
with altered pulmonary function and respiratory disease of the newborn. In this
instance, the genesis of a clinical problem was elucidated in the laboratory by col-
laboration of basic scientists and clinicians, driven by curiosity and working to sav-
ing the lives of prematurely born infants.
It was Richard Eric Pattle (1918–1980) (Fig. 14.1a), a physicist turned physical
chemist, working at the Chemical Defence Experimental Establishment, Porton
Down, Salisbury Wiltshire, in the south of England, who in studying the behavior
and prolonged stability of bubbles in pulmonary edema fluid from rabbits, which
had been subjected to war gases such as phosgene, suggested the presence of an
“anti-pulmonary edema factor.” Pattle reported that bubble films were resistant to
antifoam, and their stability “… is due to an insoluble surface layer on the

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 281
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_14, © American Physiological Society 2013
282 14 Further Developments in Fetal and Neonatal Physiology

Fig. 14.1 (a) Mary Ellen Avery (1927–2011) and Richard Pattle (1918–1980). (b) John A.
Clements. (c) Jere Mead (1920–2009)

bubbles… that must… have formed the original lining layer of the fine air spaces.”
In contrast to rather transitory bubbles from serum or other bodily fluids, these
bubbles remained stable for an hour or more. He noted that the surface tension of
the lung bubbles is therefore “zero,” and that in the small alveoli with “sharply
curved, and probably moist” walls, if surface tension were that of ordinary liquids,
“… enough suction would be exerted to fill the alveoli with a transudate from the
capillaries. Means for keeping the surface tension low must therefore be part of the
design of the lung.” Pattle continued, that it “… is thus evident that the alveoli are
lined with an insoluble protein layer which can abolish the tension of the alveolar
surface.” This unique substance also was present in the lungs from the mature fetus
as well as the adult. Pattle concluded that his findings suggest that this substance is
14.1 Pulmonary Physiology and Respiratory Distress Syndrome 283

“… secreted in the depths of the lung” (Pattle 1955, pp. 1125–1126). In a further
note, Pattle demonstrated what has been referred to by some as “Pattle’s Peculiar
Protein” (Hughes 2001, p. 4), in the lungs of birds, reptiles, and amphibians (Pattle
and Hopkinson 1963). In his major review of this field of research, including that in
the main classes of vertebrates, he detailed a number of problems to be explored,
such as: the cells of origin, the biochemistry of the surfactant protein, and the
mechanism(s) of synthesis. Pattle concluded, “The finding that the lung lining sub-
stance appears only late in foetal life … suggests that the absence of the lining
substance may sometimes be one of the difficulties with which a premature has to
contend; such a defect may possibly play a part in causing some cases of atelectasis
neonatorum … These matters need experimental investigation” (Pattle 1958, pp.
239–240). Pattle prepared several other reviews of his work (Pattle 1965, 1966).
That the pulmonary alveoli were lined with an aqueous layer, had been postu-
lated the previous year by Charles Clifford Macklin (1883–1959) of the University
of Western Ontario (Macklin 1954). Only later, was it discovered that several
decades earlier, Kurt von Neergaard (1887–1947) of the University of Zurich, pub-
lished “New interpretations of basic concepts of respiratory mechanics. The retrac-
tile force of the lung, dependent on the surface tension in the alveoli” (von Neergaard
1929). In this report, von Neergaard explored the role of surface tension as a critical
force in pulmonary expansion and contraction, demonstrating that these could not
be explained solely by elasticity of tissue elements. von Neergaard summarized his
major findings as follows.
The so-called lung elasticity – one of the fundamental concepts of the mechanism of breath-
ing – to now has been attributed … to the elasticity of the elastic fibers. Contrary to these
previously held ideas we find:
1. The total recoil of the lung consists of two components, the greater effect from sur-
face tension, the lesser important from true tissue elasticity. Quantitatively the most
important portion of the lung recoil is based on that due to the surface tension on the
terminal membrane boundary between alveolar epithelium and the alveolar air.
2. The importance of surface tension in lung recoil has been investigated experimen-
tally by measuring so-called elasticity [or pressure-volume] curves of animal and
human lungs before and after elimination of surface tension. Eliminating the surface
tension can be achieved by complete filling of the lung with a physiological gum
arabic-electrolyte solution in a differential vacuum method. By this filling, the ter-
minal membrane between alveolar epithelium and alveolar air is eliminated…
3. The measurements show that, depending on the state of expansion, the recoil due to
the surface tension is on average two or three times greater than that of the actual
tissue elasticity… From the difference between the total recoil and the partial com-
ponent of true tissue elasticity, the curve of the apparent elastic effects of surface
tension of the alveoli decreases in comparison to other physiologic solutions by
becoming enriched with surface-active substances…
4. Apart from the experimental aspect, a theoretical explanation is proposed, which is
based on the laws of surface tension and anatomy. In different ways, values for the
effect of surface tension have been calculated, which come very close to the experi-
mentally determined values. The recoil due to the surface tension is a function of the
radii of curvature of the alveoli. These conform in the expiratory phase to flat spheri-
cal sectors with a relatively large radius, i.e., a relatively small surface recoil. With
maximal inspiration, the alveoli approach their equivalent hemisphere-like shape
284 14 Further Developments in Fetal and Neonatal Physiology

with the smallest possible radius, but the effect of surface tension is great. The analy-
sis of the curves, taking into account the theory, suggests that in situations of lower
states of expansion [or stretch/elongation], the reduction in size of the alveoli brings
with it a reduction in volume of the small alveolar ducts. These test results support
the concept … regarding the supportive and stabilizing function of the elastic fibers.
With the recognition of the importance of the physico-chemical force, the sur-
face tension, one of the basic concepts of respiratory mechanics, one of the forces
necessary for life, has been transferred from the realm of morphologic viewpoint
into the area of functional classification [or evaluation].
5. The possibility of short term changes of the recoil forces of the lung exists. Firstly,
through nervous pathways the curvature of the alveoli and thus the effect of the
surface tension can be modified by the sphincter like smooth muscle structure at the
base of the alveoli. Secondly, the recoil force can be increased or decreased by fluc-
tuations in the H+-ion concentration (CO2 tension) in the alveoli.
6. The consequences of the concept of so-called elasticity of the lung in the newborn
are discussed. Here too there is a significant role of surface tension in the alveoli, an
essential factor.
(von Neergaard 1929)

von Neergaard also noted that for the newborn infant, “… a lower surface tension
would be useful for the respiratory mechanism, because without it pulmonary recoil
might become so great as to interfere with adequate expansion,” and “surface ten-
sion as a force counteracting the first breath of the newly born should be investi-
gated further” (von Neergaard 1929, pp. 393–394). (Note. Only recently did I learn
that an alternative translation has been presented elsewhere (von Neergaard 1975,
pp. 289–290)).
After pointing out several issues with Neergaard’s report, John A. Clements
(Fig. 14.1b) has written,
Neergaard’s paper will always remain a classic in the literature of pulmonary surface ten-
sion. It was the first of its kind, and its inventiveness and scholarship are legendary. It is
likely that we shall never know exactly what ideas and events led to Neergaard’s association
of surface tension with lung elasticity, but it is clear that he understood the nature of surface
tension and capillary phenomena before he did his definitive work. … His prior papers show
that he was well educated in physics, and familiar with concepts of equilibrium, mechanical
forces, and mathematical description of physical systems. He understood the origin of sur-
face tension in intermolecular attractive forces and in the asymmetry of the force field on
molecules in the limiting layer. He was aware that surface tension causes “all the phenomena
of capillary chemistry.” It appears that he was well prepared for his work on alveolar surface
tension. In fact he was building on knowledge that had been accumulating for at least three
centuries. … Neergaard’s paper was a tour de force, a beautiful creation apparently sprung
fully formed like Athena from Zeus’ brow, a startling marriage of the most sophisticated
pulmonary physiology of his time with the classical theory of capillarity. Unhappily, it was
a case of pearls before swine, for this wonderful paper was largely ignored during the next
25 years. … Perhaps von Neergaard did not promote the ideas sufficiently.
(Clements 1996, pp. 210–212)

In his insightful historical review of research on pulmonary surfactant, Julius H.

Comroe, Jr. refers to von Neergaard’s work as “premature science,” in the sense that
at that time there was no established paradigm or physiologic role to which this
discovery contributed (Comroe 1977a). Although von Neergaard attempted to iso-
late a surface active material, he was not successful (Clements and Avery 1998).
14.1 Pulmonary Physiology and Respiratory Distress Syndrome 285

Concurrently with Pattle, and independently, in attempting to understand the

basis of seemingly conflicting data from other investigators, John A. Clements and
colleagues at the US Army Chemical Warfare Laboratories, Edgewood Arsenal in
Maryland were exploring some aspects of pulmonary responses to nerve gas poi-
soning. Among other responsibilities, Clements was placed in charge of overseeing
some research on pulmonary mechanics being conducted under the aegis of a US
Army contract in Boston. This experience stimulated further his interest in pulmo-
nary surface tension. Based on the assumption that this fluid had a fixed surface
tension as that of plasma (40–50 dynes·cm−1), one investigator had calculated the
alveolar surface area to be only one-tenth that estimated from morphometric analysis
(Radford 1954). Questioning this result, Clements modified a Langmuir–Wilhelmy
balance for his studies, and developed the methodology to quantify surface tension
of pulmonary extract in several species (rat, cat, and dog). In contrast to the assump-
tion that surface tension remained constant, Clements showed that upon compres-
sion, pulmonary surfactant allowed surface tension to decrease to near zero
(~10 dynes·cm−1) (Clements 1957; Clements et al. 1961). As was clear, this was the
“anti-atelectasis factor” that allowed alveoli to remain open at end expiration, and
presented a fresh paradigm for understanding alveolar stability. Clements and col-
leagues proposed,
The uniformity of the result obtained in these several methods and preparations argues
strongly for the presence of a peculiar material on the alveolar surface. Its minimum coef-
ficient of compressibility is between 0.01 and 0.02 cm/d. This value places it in the category
of ‘liquid’ films… The film can apparently be reversibly compressed to 50 % of its initial
area. After further compression, the film apparently ruptures on re-expansion. This suggests
a solidification or gelation, or folding on marked compression which is irreversible.
(Brown et al. 1959, p. 720)

In several reports Clements has described the development of this line of inves-
tigation (Clements 1962; Clements et al. 1958), and corrected several errors sug-
gested by others (Clements 1996). As an aside, Clements’ seminal paper of 1957, in
which he announced the discovery of pulmonary surfactant, was rejected by the
journal Science, and finally was published in what he described as a non-peer-
reviewed déclassé rag. Despite the journal in which the paper appeared, it became a
Citation Classic (Clements 1997, p. 5). In 1974, Clements was elected to the
National Academy of Sciences.
A decade previously, Peter Gruenwald, a Viennese pathologist first working at
the Margaret Hague Maternity Hospital in Jersey City, and later at the Mt. Sinai
Hospital in Baltimore, had observed in infants who were stillborn, that the alveoli
were distended with fluid. In contrast, those infants who died soon after birth
showed abnormal patterns of aeration with some groups of aerated alveoli alternat-
ing with areas of atelectasis. In measuring the pressure required to inflate these
lungs, Gruenwald determined that with air this required pressure was twice that
with saline. Experimenting with a surface active compound to decrease the pressure
required to inflate the lungs with air, he concluded that surface tension plays a major
role in the initiation of breathing, and expressed doubt that hyaline membranes were
responsible for resorption atelectasis (Gruenwald 1947). Clements has written,
286 14 Further Developments in Fetal and Neonatal Physiology

Gruenwald was a prophet crying in the wilderness. He had little contact with respiratory
physiologists until ten years later (he and I became collaborators for a short time, after the
discovery of lung surfactant) … and his message, like Neergaard’s, was lost to mainstream
thought. In fairness it should be added that his observations did not explain why some
infants experienced respiratory distress and others did not.
(Clements 1996, p. 217)

Other reports noted the “liver-like” state of the airless newborn lungs, with
the presence of a “vernix membrane” (Miller and Hamilton 1949) or “hyaline
membrane” (Blystad et al. 1951; Tran-Dinh-De and Anderson 1953) lining the
alveoli. The fibrinoid content of these membranes, suggesting their origin from
blood plasma that had leaked into the alveoli, was soon established (Gitlin and
Craig 1956).
In the mid-1950s, the pediatrician/neonatologist Mary Ellen Avery (1927–2011)
(Fig. 14.1a), at the Johns Hopkins Hospital, developed a keen interest in the respira-
tory problems of the newborn as she observed too many premature infants with
RDS struggle for a gasp of air, many to die. Later working with the physiologist and
authority on pulmonary mechanics Jeremiah (Jere) Mead (1920–2009) (Figs. 14.1c)
at the Harvard Medical School and School of Public Health in Boston (Mead 1961;
Mead et al. 1957), she recognized the importance of Clements’ findings and visited
him to learn how to use the surface balance. She has written,
Around Christmas-time 1957, I drove to Edgewood and visited Clements. I saw the surface
balance, returned to Boston, and decided to explore the reason why lungs of infants who
died of hyaline membrane disease never had foam in their airways. It is obvious that the
reason they lacked foam was that they did not have surfactants with the capacity to reduce
surface tension when surface area was reduced. It was straightforward to demonstrate that
deficiency in surfactants on a surface film balance modeled after that of Clements.
(Avery 2011, p. 1082)

Avery and Mead then applied findings from the work of Clements and Pattle to
the treatment of infants with respiratory distress and hyaline membrane disease.
Regarding the nature of lung fluid extracts from markedly premature, as compared
to mature, newborn infants, Avery and Mead concluded,
The results show that without exception the surface behavior of lung extracts of the nine
infants with hyaline membrane disease was different from that of infants dying from other
causes and the same as that of infants smaller than 1,200 gm. This suggests that the disease
is associated with the absence or delayed appearance of some substance which in the nor-
mal subject renders the internal surface capable of attaining a low surface tension when
lung volume is decreased.
(Avery and Mead 1959, p. 521)

They then related their results to the pathogenesis of the disease.

Thereafter [following the first inspiration], during expiration, the alveolar surface of the
normal lung would have diminished tension [<10 dynes·cm−1]…, thus reducing the ten-
dency of the air spaces to collapse. On the other hand, in a lung lacking this lining material,
surface tension would tend to remain high [>20 dynes·cm−1] during expiration; the air
spaces would be unstable, and some would collapse.
(Avery and Mead 1959, pp. 521–522)
14.1 Pulmonary Physiology and Respiratory Distress Syndrome 287

Avery and Mead summarized their findings.

Recent observations suggest that a low surface tension in the lining of the lung may per-
mit stability of the alveoli at end-expiration. Lacking such a material, the lung would be
predisposed to collapse. Measurements of the surface tension of lung extracts confirm the
presence of a very surface-active substance in lungs of infants over 1,100–1,200 gm, and
in children and adults. In lung extracts of very small premature infants and infants dying
with hyaline membrane disease the surface tension is higher than expected, suggesting
that the surface active material is deficient. The possible role of this deficiency in the
pathogenesis of hyaline membrane disease is discussed.
(Avery and Mead 1959, p. 523)

Avery has noted the financial circumstances of grant support (or lack thereof) for
these now classic studies.
It is perhaps pertinent to note that the studies done in 1957–59 were as a special fellow of
The National Institute of Neurological Diseases and Blindness, but without any separate
grant support. The facilities and supplies were provided by the Department of Physiology,
Harvard School of Public Health, but since all the equipment was assembled from laboratory
leftovers, the cost was minimal. I made the first trough from a wooden slide box lined with
paraffin; only after the original observations did we splurge on a teflon trough, made by a
plastics manufacturer in Cambridge.
The essential attribute in the environment was the encouragement to pursue new ideas,
and a receptivity even to their initial halting presentation…
(Avery 1977, p. 3)

As noted by Nicholas Macy Nelson, Emeritus Professor of Pediatrics at

Pennsylvania State University and who had worked in Boston with Clement Smith,
Present-day Fellows who have had their ‘breakthrough’ research underappreciated can take
heart from the pediatric Alte Herren [old men] of 1959 that Mel’s paper on the high surface
tensions she found in [premature infant] lungs was of insufficient interest [to be accepted]
for presentation at the spring pediatric meetings.
(Nelson 2008, p. e4)

This work of Avery and Mead was to provide a scientific rationale for the treat-
ment of respiratory distress syndrome in the newborn with continuous positive air-
way pressure (CPAP; see below). Later, upon returning to the Johns Hopkins
University in Baltimore, in a study comparing two 5 year periods (1944–1948 and
1954–1958), in which the first group had experienced higher ambient oxygen con-
centrations important in the pathogenesis of retrolental fibroplasia, Mary Ellen
Avery and Ella Hutzler Oppenheimer (1897–1981), described the pathologic find-
ings in the lungs in live-born, premature infants who had died of hyaline membrane
disease. Of interest in this regard, they found no significant difference between the
two groups (Avery and Oppenheimer 1960). Avery was the recipient of many
awards and honors. Among others these include: the National Medal of Science
from President George Herbert Walker Bush (1991), election to the National
Academy of Sciences (1994), President of the American Association for the
Advancement of Science (2003), and receipt of the American Pediatric Society’s
highest award, the John Howland Medal (2005) (Hostetter 2005). Avery has pre-
sented a historical review of hyaline membrane disease, including: categorizing the
critical observations, epidemiology, diagnosis, surfactant and its physiologic role
288 14 Further Developments in Fetal and Neonatal Physiology

and biosynthesis, approaches to therapy, and early studies on prevention with ante-
natal glucocorticoids (Farrell and Avery 1975), and has recounted some personal
aspects of her vital contributions (Avery 1975, 1995, 2000, 2011; Avery et al. 1986).
At the time of Mary Ellen Avery’s receipt of the John Howland Medal, Lewis R.
First of the University of Vermont, sang a song from the Broadway show “Mame,”
with the lyrics rewritten,
You helped the tiniest infants survive – Mel
You made neonatology thrive – Mel
You’ve mentored thousands of trainees
And given us advice that’s always right.
You’ve smartened all of our brainees
And helped us set our goals and hit new heights!
Tonight we all just want to say wow – Mel
You’ve earned the award we fondly call How – Mel
Your many contributions
Have helped children who are sick and who are well.
We owe so much to what you’ve done
From you we’ve learned at least a ton
To us you’re truly number one – here’s to Mel!
(Hostetter 2005, p. 1315)

Observing the previous era of surfactant research as rather “monastic,” John A.

Clements has written,
With Avery and Mead’s publication … the subject entered its secular phase. … The flood
gates were open, and everyone could see the potential applications to clinical problems.
Surfactant research became respectable, grant money started to flow into it, and an expo-
nential increase in publications began. Over the next 35 years the field diversified and
became fair game for biochemists, anatomists, cell biologists, molecular biologists, and
therapeutic adventurers, myself included. Nowadays, surfactant substitution treatment
saves the lives of thousands of infants with respiratory distress syndrome every year and
substantially reduces the cost per survivor, and it may well be applicable to other lung dis-
eases. While the necessary knowledge was being painfully extracted from a reluctant
Mother Nature, a rich harvest of information was garnered about lung biology, hormonal
control of development, and several related subjects. Some observers of the history of sur-
face tension in the lungs may bemoan the loss of our monastic Weltanschauung [conception
of the world]. Not I.
(Clements 1996, pp. 225–226)

Following these discoveries, a number of questions became evident regarding this

substance that could lower the surface tension in alveoli with changes in the respira-
tory cycle (Comroe 1977a, b, c, d). Julius Comroe summarized these succinctly,
What is surfactant? Where does it come from, where does it go and what regulates its for-
mation and movements? Can it or a similar substance be prepared synthetically and used as
replacement therapy? Can the physician, instead of nature, make an immature lung become
mature? Can the physician not only maintain the life of a newly born baby until the lung
matures but also ensure normal postnatal function of all organs?
(Comroe 1977c, p. 497)

On the basis of roentgenographic evidence, hydrostatic pressure changes, and latex

filling of the vessels, earlier Charles C. Macklin had suggested that inspiration and
expiration are associated with distension and contraction, respectively, of the
14.1 Pulmonary Physiology and Respiratory Distress Syndrome 289

pulmonary arteries and veins, with them serving as an “accessory heart.” He referred
to this as the “lungbeat” that mirrored the heart beat (Macklin 1946, p. 229). Later,
Macklin postulated that alveolar type II cell (pneumocyte) was the source of the lining
layer of the alveoli, which he believed was mucoid and maintained “… constancy of
the surface tension of the alveolar wall … a matter of paramount importance”
(Macklin 1954).
At this point, a critical challenge for clinicians was that of identifying before birth
those infants who would be born prematurely without adequate pulmonary surfac-
tant. By biochemical analysis, in 1961 three groups discovered that the surface active
compound contained a large component of phospholipids as well as protein. Clements,
having joined the faculty at the University of California San Francisco, with his
colleagues established that phospholipid dipalmitoyl phosphatidylcholine (lecithin)
was the most abundant component, and a critical surface active compound (Klaus
et al. 1961). With the use of infrared absorption spectroscopy, Pattle and a col-
league also demonstrated that lecithin was a component (Pattle and Thomas 1961).
The same year, Sue Buckingham (1923–1969) of Johns Hopkins, recognized in sheep
the phospholipid nature of this material (Buckingham 1961). In the developing
mouse, Buckingham with Avery then demonstrated the temporal correspondence
between the appearance of osmiophilic lamellar inclusions in alveolar type II cells
and the capacity to lower surface tension (Buckingham and Avery 1962). Later stud-
ies would establish the role of these osmiophilic lamellar bodies as the origin of the
phospholipids of pulmonary surfactant. For instance, by subcellular fractionation
Clements and coworkers demonstrated that the mitochondrial fraction of alveolar
cells provided the richest source for this activity (Klaus et al. 1962; also see Clements
1997; Clements and Avery 1998), presumably because it included type II cell lamel-
lar bodies.
A decade later, by analyzing fluid from the newborn lung as a function of
gestational age, Louis Gluck (1924–1997) (Fig. 14.2a) with his colleagues at the
University of California San Diego, established that lecithin increases dramatically
at ~35 weeks of gestation. By measuring in amniotic fluid the concentration ratio of
lecithin (L) to sphingomyelin (S), (the latter of which remains constant or decreases
slightly, e.g., the L/S ratio), Gluck provided clinicians with a diagnostic tool, the
L/S ratio to gauge the maturity of the developing fetus, and in instances of prema-
ture labor, to alert attending physicians to the need for special care (Gluck et al.
1971; Gluck and Kulovich 1973). The following year, Clements with coworkers
described a relatively simple qualitative “shake test” that could be performed at the
bedside to establish the degree to which adequate disaturated lecithin was present in
the fetal pulmonary and amniotic fluid, and therefore be predictive for respiratory-
distress syndrome (Clements et al. 1972). The Clements group also identified a
surfactant-specific protein (King et al. 1973), that subsequently led to the discovery
of several proteins (surfactant proteins A to D) associated with the lipids of pulmo-
nary surfactant (Wright and Clements 1987). A number of other aspects of the bio-
chemistry and physiology of pulmonary surfactant have been reviewed (Halliday
2008; Tierney 1989; Van Golde et al. 1988), as well as that of respiratory distress
syndrome (Reynolds 1975; Stahlman 1984; Tooley 1977).
290 14 Further Developments in Fetal and Neonatal Physiology

Fig. 14.2 (a) Louis Gluck (1924–1997). (b) Maria Delivoria-Papadopoulos and Paul R. Swyer.
(c) Leonard B. Strang (1925–1997) and Sir Robert Boyd

Following the discovery and introduction of the animal-derived Tokyo-Akita

(TA) surfactant for replacement of deficient surfactant in the lungs of RDS prema-
ture newborns (Fujiwara et al. 1980), the field of exogenous surfactant therapy of
such infants has been revolutionized (Collaborative European Multicentre Study
Group 1992). Thurman Allen Merritt with the Gluck group in San Diego and Mikko
Hallman of the University of Helsinki, Finland, pursued studies on the benefits of
surfactant therapy for infants with RDS. For instance, in five very low birthweight
(<1,000 g) RDS infants a bolus of human surfactant isolated from amniotic fluid at
the time of cesarean section, produced a dramatic improvement of symptoms and
blood gas values which lasted 8–15 h (one infant later died) (Hallman et al. 1983).
This group also showed that 22 infants of similar RDS status demonstrated dramatic
improvement with a lower rate of complications, compared to the controls which
received only intermittent ventilation (Hallman et al. 1985). In an expanded clinical
trial of preemies (24–29 week gestation with RDS, a L/S ratio <2, and absence of
phosphatidylglycerol), 31 surfactant treated infants showed significantly less
14.1 Pulmonary Physiology and Respiratory Distress Syndrome 291

requirement for respiratory support, and fewer cases of bronchopulmonary dysplasia,

pulmonary interstitial emphysema, or pneumothorax. The number of deaths in this
group was less than one-third that of controls (Merritt et al. 1986). These dramatic
results were confirmed in an even larger study of surfactant treated RDS preemies,
however, “rescue treatment” given almost 4 h after birth showed no significant
improvement (Merritt et al. 1991).
As is well remembered, the disastrous epidemics of poliomyelitis in the first half
of the twentieth century, and particularly by mid-century, struck fear in the hearts of
all, regardless of ethnic group or social status. These almost annual plagues had a
profound impact on society and medicine (Daniel and Robbins 1997; Paul 1971). To
help compensate for the polio-associated central nervous system bulbar respiratory
failure and weakened respiratory muscles, use of the Drinker style negative pressure
“Iron Lung” helped to preserve many whose lives otherwise would have been lost
(Drinker and McKhann 1929). In this era, a major problem in the management of
infants was ventilation in those with respiratory distress syndrome. Modification of
the “Iron Lung” and other inventions played a key role in saving the lives of infants
with this disease. Although it is unknown who first used assisted ventilation for
infants, the Scottish-born American inventor Alexander Graham Bell (1847–1922)
designed and built a whole body, negative pressure respirator for use with new-
borns. Presented at a Montreal meeting of the American Association for the
Advancement of Science, his contribution “… met with little enthusiasm” (Stern
1970, p. 24). In the late 1950s and early 1960s, several groups refined this modality,
using negative pressure for infants with respiratory failure (Stahlman et al. 1965).
Leo Stern of the Montreal Children’s Hospital, McGill University described in
some detail the experience of that group, and the criteria for such therapy (Stern
1970; Stern et al. 1970). Other early workers employed intermittent positive pressure
ventilation for this purpose (Adamson et al. 1968; Heese et al. 1963; Owen-Thomas
et al. 1968; Swyer 1970; Thomas et al. 1965). Complicating this picture, however,
were reports of severe “respirator lung” disease (now known as bronchopulmonary
dysplasia) with a high mortality rate that followed these endeavors (Hawker et al.
1967; Northway et al. 1967). A 1969 Paris conference of experts weighed the role
of assisted ventilation in the treatment of these infants, and considered the extent to
which the possible complications outweighed the potential benefits (Minkowski
et al. 1970; Philip 2003).
Despite these setbacks, long-term positive pressure ventilation proved its value
(Donald and Lord 1953; Donald et al. 1958; Smythe and Bull 1959). For instance,
on the basis of observation of 150 infants with respiratory distress syndrome over 4
years, Robert Usher of the Royal Victoria Hospital, Montreal, reviewed many fea-
tures of the disease. In addition to assisted ventilation with oxygen, he stressed the
need for intravenous glucose and sodium bicarbonate to correct hypoglycemia, aci-
dosis, and electrolyte imbalance with hyperkalemia (Usher 1959, 1961). Of interest,
the editor of the journal in which one of his original papers was published amended
a series of seven caveats concerning the validity of Usher’s recommendations
(Usher 1961).
292 14 Further Developments in Fetal and Neonatal Physiology

About this time, Maria Delivoria-Papadopoulos and Paul Robert Swyer

(Fig. 14.2b), at the Hospital for Sick Children and the University of Toronto, reported
on a rather extreme case for that time, of an 1,800 g infant of 34 weeks gestation,
who with assisted pulmonary ventilation, survived cardiorespiratory arrest and RDS
with no neurological sequelae at 6 months of age (Delivoria-Papadopoulos and
Swyer 1964). Shortly thereafter, George Albert Gregory and the San Francisco
group reported their striking success with the use of continuous positive airway
pressure (CPAP), rather than intermittent pressure, in the management of premature
infants with respiratory distress syndrome (Gregory et al. 1971). The dramatically
improved oxygenation demonstrated by these workers, no doubt was a consequence
of ventilating incompletely collapsed air spaces, as well as reducing regional vascu-
lar resistance and the right-to-left shunt. Of 20 infants studied, 16 survived (80 %)
including 10 that weighed less than 1,500 g at birth. This compared with a survival
rate of 20 % or less in the controls (Gregory et al. 1971). Soon, other reports verified
the use of CPAP in increasing survival of infants with RDS (for instance see
Krouskop et al. 1975). Because oxygenation is a function of mean airway pressure,
the use of positive end-expiratory pressure can result in requirements for high peak
inflation pressure and fractional concentration of inspired O2 (Boros et al. 1977;
Delivoria-Papadopoulos 2003). Gregory has given an historical account of the
development of CPAP (Gregory 2004).
As noted, pulmonary surfactant has been shown to contain a lipid component,
disaturated phosphatidylcholine, and a complement of several proteins, surfactant
proteins (SP)-A, (SP-A), SP-B, SP-C, and SP-D, the synthesis of both components
of which is stimulated by cortisol (Liggins 1994; Rooney 1985). In the main, these
proteins are produced by so-called type II pneumocytes or alveolar cells. As an
aside, several of these proteins (SP-A and SP-D) also may play a critical role in
stimulating immune responses, thus modulating host defense in the lungs, protect-
ing against infections to which the newborn is vulnerable (Wright 2006). As noted,
following the discovery of surfactant, the race was on to develop and patent the
“Holy Grail” of synthetic substitutes, artificial surfactant, to be used on infants with
respiratory distress syndrome, and to discover the methods to administer these com-
pounds in the optimal manner (for review see Comroe 1977c; Robillard et al. 1964;
Scarpelli 1995). Nonetheless, despite all that has been learned concerning the com-
position and function of pulmonary surfactant, little is known of the fundamental
cellular and molecular mechanisms that regulate prenatal type II cell maturation,
surfactant protein and lipid synthesis, and related mechanisms and phenomena
(Perez-Gil and Weaver 2010). As a measure of success, with advances in the under-
standing of pulmonary physiology of the newborn infant, in the USA the number of
infants who die from RDS has dropped exponentially from that of the 1950s to the
present.
During this period, several other problems concerned fetal–neonatal pulmonary
physiology. One was the urgent need to quantify certain aspects of pulmonary func-
tion in the newborn infant. This was advanced by development of a body plethys-
mograph with a pneumatic cuff seal for such studies by Kenneth William Cross of
St. Mary’s Hospital Medical School, London (Cross 1949; Cross and Warner 1951).
14.1 Pulmonary Physiology and Respiratory Distress Syndrome 293

Another problem was that of understanding the factors that regulated fluid secretion
in the lung of the fetus, and its reabsorption in the newborn following birth, as con-
flicting findings had been reported in terms of fluid dynamics and mechanisms.
Following a report that the periarterial tissue and lymphatic vessels of the lungs of
newborn rabbits were quite distended with eosinophilic staining liquid (believed to
be rich in protein; Aherne and Dawkins 1964), the pediatrician–physiologist
Leonard Birnie Strang (1925–1997) (Fig. 14.2c) of University College Hospital
(UCH), London, tackled this problem. For a number of years, he was at the
Postgraduate Medical School, Hammersmith Hospital, London. Later, he worked at
the Nuffield Institute with Dawes, and then with Clement Smith in Boston. In the
lamb and newborn infant Strang performed a series of studies to establish some
basics such as the mechanisms of liquid uptake from the lungs, showing a striking
increase in lymph flow during the first hours following the onset of respiration
(Strang 1967). He also performed a series of studies on growth and development of
the fetal lung, pulmonary permeabilities of ions and nonelectrolytes, fluid secretion
rates, composition, and mechanisms, fluid reabsorption following birth, the role of
thyroid hormones and hydrocortisone in the reabsorptive process, and so forth. In a
monograph (Strang 1977b) and several reviews (Strang 1976, 1977a, 1989, 1991),
Strang summarized his work. These studies were crucial to understanding some
basic features of the lung during the perinatal period. In 1990, Strang was awarded
the James Spence Medal for “… excellence in research, in teaching, and in clinical
care,” by the British Paediatric Association (now the Royal College of Paediatrics
and Child Health) (Lloyd 1990; Oliver 1997). (Other neonatologists and physiolo-
gists who previously had received that distinction included: Robert A. McCance
1961; Geoffrey S. Dawes 1969; Kenneth W. Cross 1979; Elsie May Widdowson
1981; Sir Peter Tizard 1986).
Regarding Strang and the Postgraduate Medical School at the Hammersmith
Hospital, John Burnard West, of the University of California San Diego has
written,
We were together in the Postgraduate Medical School at Hammersmith Hospital … for
several years starting in the late 1950s. Another Australian, Kemp Fowler, had just built the
first mass spectrometer specifically designed for medical research and we were busy trying
to get as much information as we could from expired gas. The mass spectrometer gave a
rapid readout of Po2, Pco2, and PN2. I remember that Leonard worked on a method of mea-
suring blood gases by equilibrating a small bubble of air with blood, and subsequently
measuring the Po2 and Pco2 in the air bubble using the mass spectrometer. This, in effect,
was an extension of the method introduced by Richard Lord “Dick” Riley [1911–2001] at
[Johns] Hopkins for measuring blood gases. [see Permutt 2002] I don’t think much came of
Leonard’s work in this area, or at least I cannot see a publication related to it on PubMed.
However, blood gas electrodes began to be used shortly afterwards so maybe that put an end
to that line of research.
I knew Leonard and his first wife fairly well and used to visit them in Barnes from my
flat in Hammersmith. We spend some evenings playing chess together. I also visited
Leonard when he was working in the Nuffield Institute with Geoffrey Dawes, and I remem-
ber attending an experiment where they were looking at pulmonary vascular resistance in
the newborn lamb.
I spent a year with Hermann Rahn (1912–1990) in Buffalo in 1961–62 and Leonard was
in Boston at the same time. I visited him on one occasion in their home to the west of
294 14 Further Developments in Fetal and Neonatal Physiology

Boston. An incident here made an impression on me. Leonard had a health problem (it may
have been a renal stone) and the first thing he did was take a flight back to London. I some-
times cite this as an example of the fact that a good test of where somebody regards his
home is where he goes if he gets sick.
As I am sure you know, Leonard was a great Francophile. I think he had spent vacations in
France as a medical student. After he retired from UCH he went to live in Volx in Haute
Provence. My wife and I visited him and his second wife there on a couple of occasions. Leonard
tried hard to integrate himself into the local community although I am not sure how successful
that was. Volx was very parochial and few foreigners lived there. I know that Leonard spent some
of his time translating [the French novelist and critic Marcel] Proust [(1871–1922)].
Leonard was one of the most charming, generous and good-natured persons that I ever
knew. He coped with his disability very well although I think when I visited him in Volx he
found getting around rather tiring. He was a wonderful person and many people at UCH
remember him very happily.
(Letter from JBW to LDL, 24 August 2010)

14.2 Corticosteroids and Maturation of the Fetal Lung

Along this line, as is widely recognized the cellular and molecular biology of growth
and development of the lung is extremely complex (Copland and Post 2004).
As noted earlier, it was in fetal sheep in the early 1960s, that Liggins and his cowork-
ers at the University of Auckland demonstrated the ability of adrenal glucocorticoid
hormones to induce the enzymes required for surfactant synthesis, and thus matura-
tion of the lungs of the premature infant (Liggins 1969, 2000; Mescher et al. 1975).
In five of the cattle with prolonged gestation due to pituitary and adrenal anomaly
referred to above delivered by hysterotomy, these authors administered hydrocorti-
sone for up to 4 days following delivery in an attempt to optimize their respiration
(Holm et al. 1961). Liggins later recorded,
I remember one morning … there was a lamb lying in a cage with its mother. A lamb that
had been infused as a fetus with cortisol. And to my surprise this lamb was still breathing,
not very healthy breathing, but it was alive and breathing. It had no right to be. It was so
premature that its lungs should have been just like liver, and quite uninflatable. And this
struck me as surprising.
(Watts 2010, p. 1140)

The value of steroids soon was confirmed by Avery and her group (DeLemos
et al. 1970). Liggins and the pediatrician Ross Nisbet Howie (Fig. 14.3a) of the
National Women’s Hospital, Auckland, later reported a clinical trial of 213 mothers
in spontaneous premature labor, or who otherwise were to be delivered before 37
weeks, who were given betamethasone. In 77 % of the 117 mothers so treated, delay
in delivery of at least 24 h was achieved. In these infants, the incidence of both
respiratory distress syndrome and neonatal mortality were markedly decreased (9 %
vs. 26 %; P < 0.01; 3 % vs. 15 %; P < 0.01, respectively). None of the infants whose
mothers received steroid, died of hyaline membrane disease or intraventricular
cerebral hemorrhage (Liggins and Howie 1972). Liggins later recorded that the
manuscript for this paper initially was submitted to the journal Lancet, but “… was
14.2 Corticosteroids and Maturation of the Fetal Lung 295

Fig. 14.3 (a) Ross Howie and “Mont” Liggins, 1972. (b) Jeffrey Robinson, “Mont” Liggins, and
Geoffrey Dawes

rejected on grounds of lack of general interest” (Liggins 1982, p. 305). In the fetus,
Liggins and colleagues also demonstrated that variables such as lung volume and
levels of saturated phosphatidylcholine, the major surface active component of pul-
monary surfactant, were correlated more closely with cortisol levels than with ges-
tational age (Kitterman et al. 1981). Others demonstrated the value of glucocorticoids
in lung maturation in the fetal baboon (Kotas and Kling 1979).
Mary Ellen Avery has made several important points in regard to the challenges
of antenatal steroid use. First, she pointed out that it was Florence Moog (1915–
1987), an anatomist at Washington University, St. Louis, who in studies of the
appearance with maturation of phosphatase in the duodenum of the suckling mouse,
demonstrated the role of glucocorticoids in mediating this response (Moog 1953).
Thereby, Moog’s studies initiated the idea of the role of hormones on organ matu-
ration. These observations stimulated Sue Buckingham to test this idea,
296 14 Further Developments in Fetal and Neonatal Physiology

demonstrating in the fetal rabbit the role of corticosteroids in maturation of pulmo-

nary phosphatase (Buckingham et al. 1968). Unfortunately her untimely death pre-
vented her from completing more definitive studies along this line of investigation.
Avery also has commented on the lack of enthusiasm, and, in fact, overt hostility
on the part of professional colleagues, reviewers of manuscripts and others, regarding
the antenatal administration of glucocorticoids to pregnant women in the event of
preterm labor (Avery 1984a, b). For instance, she quotes one such hostile reaction,
…the article under discussion deals simply with long-term follow-up rather than efficacy in
preventing the problems of prematurity. (In fact, their data show no significant differences
between treated and placebo groups with regard to weight or gestational age at delivery).
In the collaborative study on steroid administration, there was no significant difference in
effect of steroids, except in a very small subgroup of white, non Hispanic patients. Dr.
Avery’s final sentence ‘The failure to do so (treat with glucocorticoids) is costly in terms of
morbidity and, I believe, constitutes poor practice,’ is clearly a biased opinion and inap-
propriate … Their use is still experimental and should be limited to those institutions where
protocols can be strictly adhered to … After a follow-up program of only 3 years, and a
questionable risk/benefit ratio, Dr. Avery’s dare to use steroids for this indication or practice
poor medicine has no place in either modern perinatology or The Journal.
(Avery 1995, p. 134)

Avery recalled the tongue-in-cheek wisdom of the German philosopher Arthur

Schopenhauer (1788–1860) regarding the response to new ideas.
The first response is that it is ignored. The second is that it evokes hostility in the form of
many attempts to disprove it. Finally, it merges in with the collective wisdom so that the
response is “haven’t we known this all along?”
(Avery 1995, p. 133)

Several years following the introduction of corticosteroids, a large prospective

double blind study demonstrated the role of antenatal steroids in the prevention of
respiratory distress syndrome in those infants who were markedly premature (inci-
dence of 21 % vs. 59 % in non-treated controls, with both severity less and death
rate lower, P < 0.05 for each; Papageorgiou et al. 1979). With these studies, a new
era of fetal–neonatal medicine was launched. Nonetheless, it was a decade until a
1994 NIH-sponsored “consensus” advocated antenatal steroid treatment in women
in spontaneous premature labor (NIH 1994), and the use of this modality became
“standard practice.” A late twentieth century meta-analysis of randomized trials of
antenatal corticosteroid therapy from 1972 to 1994, provided irrefutable evidence of
the efficiency and virtue of such therapy (Crowley 1995). To accelerate fetal pulmo-
nary maturation and the production of surfactant, a 2000 NIH Consensus Conference
Antenatal Corticosteroids Revisited and Repeat Courses recommended further that
a single course of antenatal steroid therapy be given for pregnant women between
24 and 34 weeks gestation who are at risk of delivering within 1 week. They con-
cluded that the then current benefit-risk data were insufficient to support the routine
use of repeat or rescue courses of antenatal corticosteroids (NIH 2000). A decade
later, the Gainesville group demonstrated the role of pulmonary mineralocorticoid
receptors in mediating the composition of fluid in the fetal lungs (Keller-Wood et al.
2011). Liggins has reviewed the major organ systems, including the thyroid gland,
14.3 A Tribute to “Mont” Liggins 297

lungs, liver, and adrenal, in which a maturational response to glucocorticoids has

been demonstrated (Liggins 1994). He also wrote a thoughtful account of these
many contributions (Liggins 2000).
The widespread use of antenatal glucocorticoid therapy to enhance fetal lung
maturation, also has stimulated investigation of the extent to which this alters the
function of the hypothalamic–pituitary–adrenal axis. Several studies, in fact, suggest
that this is the case in terms of attenuated adrenal cortical response to stimulation
(Davis et al. 2004, 2006; Ng et al. 1997). Clearly, many factors are involved in hypo-
thalamic–pituitary–adrenal axis regulation, and these must be taken into account in
terms of antenatal programming of adult health and disease (Rose et al. 2011).
A related major issue in this regard, is that of the regulation of the growth and
development of the lung. Beyond the maturing morphology (Burri 1984), is that of
signaling networks (Ornitz and Yin 2012), growth factors (Alphonse and Thebaud
2011; Meller and Bhandari 2011), mesenchyme (Ahlfeld and Conway 2012), and
even the mechanical movements per se in stimulating cell proliferation (Skinner
1989). As can be appreciated, this topic requires an extended chapter of its own.

14.3 A Tribute to “Mont” Liggins

At a 1988 symposium in Rotorua, New Zealand, Advances in fetal physiology…, to

mark “Mont” Liggins’ retirement from teaching and clinical responsibilities, four
dozen associates and fetal-newborn physiologists from around the globe gathered
to review their latest work and to honor the “Master of New Zealand Midwifery.”
As noted by the organizers,
Few individuals have had such impact on the development of a field of science as Mont
Liggins has had on the development of fetal physiology over the past two decades. Mont
has had a significant influence on many aspects of fetal physiology. He pioneered the exper-
imental use of the fetal sheep for studies of fetal physiology. His discoveries of the role of
glucocorticoids in the maturation of the lung and on the initiation of parturition determined
the path of fetal physiology for many scientists. He contributed to the rediscovery of fetal
breathing movements and has studied the significance of these and hormonal factors in lung
maturation. Other interests have included the control of fetal growth and fetal prostaglandin
physiology. His studies of the pregnant diving seal show the diversity of his interests. His
personal qualities have endeared him to colleagues throughout the world.
(Gluckman et al. 1989, p. v)

For the evening’s banquet, David J. Mellor of New Zealand’s Massey University
prepared “A Tale of Mont (or a Montage of Events).”
In the ‘50s and ‘60s physiologists well knew
That oxygen became short as the fetus grew,
And therefore proposed that to escape this dearth
Mechanisms unknown made the mother give birth!
But then we all learnt from Barron at Yale
That such hypoxia’s a myth, supply doesn’t fail!
298 14 Further Developments in Fetal and Neonatal Physiology

While some workers thought the fetus was passive,

Most thought it a parasite, its burden so massive
Its demands would increase ‘till burden so massive
Its demands would increase ‘till the dam was compelled,
By dint of long straining, to see it expelled!
And thus it was by most fetologists figured
That the process of birth was by the mother triggered!
There now enters one who is known to us all,
He’s casually dressed and not very small,
He hails from New Zealand, the islands ‘down-under,’
And he sets about blowing these theories asunder,
For he saw that the fetus with a hole in the head
Would stay in the uterus until it was dead!
Of course it was Mont who cleared the confusion
By causing early birth with a fetal infusion;
He showed us how the adrenals get bigger
To help produce cortisol, the fetal trigger
Which breaks down the barriers that prevent admission
To the outside world at parturition.
But not only that, for Mont was to show
How cortisol’s needed to make the lungs grow,
And with other hormones acting they also mature,
So the young once born can easily procure
The oxygen it needs in its first vital breath,
Without which new life soon leads to death!
This ‘Tale of Mont’ having progressed thus far
Now sees him working in Antarctica;
But the scene’s not pretty, our tone must descend,
For there’s Mont with his arm up a seal’s rear end;
The danger’s not small and nor is the smell,
But a progesterone test will do just as well!
Few would dispute that Mont is a winner,
Certainly no one attending this dinner,
Most pause to listen when he rises to speak,
He’s a mountain among us, a veritable peak,
He’s no mere knoll, he’s one of our big ‘uns,
The tallest among us – we salute Mont Liggins! – David Mellor, July 1988
(Mellor 1989, p. vii)

In his introduction to this symposium, Geoffrey Dawes reviewed “Mont”

Liggins’ many contributions to science and to life (Fig. 14.3b). These included not
only studies on the role of the fetal hypothalamic–pituitary–adrenal axis in the tim-
ing of parturition, but the role of glucocorticoids in development of the lung, and the
value of antenatal glucocorticoid therapy in lung maturation in women with impend-
ing premature labor. In regard to Liggins’ studies Dawes observed, “… the impact
of this discovery on perinatal research was great. Here was evidence of endocrine
participation in the physiological preparation for birth. The impact has not yet sub-
sided.” He cautioned, however, “The details of the cellular mechanisms are still
controversial, and yet further attention has been directed to lung structural
14.3 A Tribute to “Mont” Liggins 299

development, as a determinant of viability” (Dawes 1989, p. 5). Dawes concluded

by remarking upon Liggins’ studies in the Weddell seal, and not only its cardiovas-
cular responses to both water immersion and free diving (Dawes 1989; Zapol et al.
1979), but the implications for the fetus-in-utero (Hill et al. 1987). Dawes con-
cluded his tribute to Liggins, a consummate fetal physiologist and fellow fly-fisher-
man, with a quote from Izaak Walton (1593–1683) that there “… is another reason
of the preference accorded to it, since there is more merit and therefore more plea-
sure, in excelling in what is difficult” (Dawes 1989, p. 10).
As an aside, from the Sovereign of the United Kingdom in 1980 Liggins received
the Polar Medal for his studies in Antarctica. That same year, the Royal Society of
New Zealand awarded Liggins the Hector Medal (in honor of Sir James Hector
(1834–1907)) for his outstanding scientific research. A decade later (1991) the
Queen knighted Liggins, and in 2002 upon her visit to New Zealand, Queen
Elizabeth II officially opened the perinatal research unit, named in his honor, the
“Liggins Institute,” at the University of Auckland.
One who spent several sabbaticals working with Liggins, Robert Kenwood
Creasy (Fig 20.1o), formally of the University of California San Francisco and the
University of Texas, Houston, has written,
Not much question that he and Dawes opened up the science of fetal physiology. Although
initially interested in oral contraception, and assisting with fetal hemolytic disease studies,
he soon began his career-defining pursuit, namely the etiology of parturition. He decided to
follow a recent hypothesis that the onset of labor was initiated by the fetus, and not the
mother as most held, and developed a series of innovative techniques in a chronic sheep
model. Mont’s quest, initially very much on his own, and with VERY meager support or
direction from others, developed the ability to discern the role of the fetal pituitary through
a rather ingenious method of transecting the pituitary stalk in a living fetus. He then went
on with others, such as Geoffrey Thorburn of Australia to elucidate the mechanism of the
onset of parturition in the sheep. Unfortunately, despite his efforts that mechanism of par-
turition in humans was still not known at the time of his passing away. However, he was
able with his intellect to show that the fetus plays a key role in humans as well.
With these techniques he was able to induce premature delivery by giving ACTH or
cortisol to the fetus. He then recognized the importance of the unexpected, namely that the
prematurely delivered fetus has partly aerated lungs at a time when they should have been
solid. From the above observations to a rigidly controlled clinical trial, he established that
the use of antenatal steroid administration to mothers about to deliver prematurely would
dramatically lower respiratory distress syndrome and demise in the human neonates. This
result has had a major clinical impact throughout the world and was arguably the most
important single advance in obstetrical care in the last half century.
He then continued his parturitional studies further elucidating various processes
involved, frequently collaborating with the world’s leading fetal physiology investigators.
He also continued to be involved with studies of the fetal lung. Indeed his counsel and
wisdom were continually sought after by visiting investigators throughout the years. He
always remained interested in helping those interested in a research career and or clinical
medicine. He also played a significant role for many years in investigating the diving mech-
anisms in pregnant Antarctic seals and their fetuses. These studies were productive and
resulted in many novel concepts.
Lastly, having worked with Mont in multiple settings in New Zealand, Antarctica, and
the US, and with a wide variety of people, it was remarkable to see him drop everything he
was working on and concentrate on helping others, including my two small children when
300 14 Further Developments in Fetal and Neonatal Physiology

they would come bouncing into the lab on a Saturday morning. He gave major advice to
many on their various projects, including my own quest to develop a model of fetal growth
restriction in the sheep that would mimic much of that seen in humans.
A true friend and mentor to a very large number of scientists, and certainly one of the
Fathers of Fetal Physiology.
(Letter from RKC to LDL 26 May 2012)

As must be clear, this example of the manner in which basic physiology and
biochemistry have interacted with clinical medicine to relieve suffering and save
lives, is one of the most noble examples of the possibilities of translational medicine
that one can imagine.

14.4 Blood and Hematology

In early gestation, erythrocytes are produced in the embryonic yolk sac, liver, and
perhaps tissues other than bone marrow. The erythrocytes formed are of larger size,
nucleated, and contain more hemoglobin, than those of later gestation. During the
course of gestation these fetal erythrocytes demonstrate a number of unique charac-
teristics (Keleman et al. 1979). In the late nineteenth century, on the basis of alkali
denaturation rates in adults and newborn infants, Ernst Körber (ca. 1832 to ca. 1896)
of the University of Dorpat, first demonstrated that fetal hemoglobin differed from
that of the adult (Körber 1886). This was substantiated several decades later (von
Krüger 1888). As is well established, the hemoglobin molecule consists of four
heme groups (an organic moiety, protoporphyrin, and central iron atom) bound to
the protein globin. The primary structure of hemoglobin is genetically determined
by the globin chain amino acid sequence. During the mid-1930s and thereafter,
several studies established the nature of the hemoglobin of the fetus (Hgb F), as
opposed to that of the adult (Hgb A) (Brinkman and Jonxis 1935, 1936; Huehns and
Beaven 1971; Jonxis 1949; Schroeder 1980). The resistance of fetal hemoglobin to
acid elution distinguishes these cells from those of the adult (Kleihauer et al. 1957),
a characteristic used to detect fetal erythrocytes in the maternal circulation. In a
series of studies on the development of embryonic hemoglobin, Ernst Reinhard
Huehns of University College London with colleagues examined the blood of
human embryos of gestational age <90 days by starch gel electrophoresis. By
measurements of electrophoretic mobility, absorption spectrum and alkaline dena-
turation, these workers demonstrated new hemoglobins Gower 1 and 2, consisting
of epsilon chains (zeta2 epsilon2 and alpha2epsilon2, respectively). These represent
the earliest globin chain synthesis in the embryo, preceding that of gamma chains
and later the beta chains (Huehns et al. 1964a). These workers also illustrated the
dramatic changes in non-alpha chains during the course of gestation (Huehns et al.
1964b). Recent years have witnessed fresh insights into the complexities of the
developmental molecular mechanisms of the beta globin switch, by which gamma
globin expression is silenced. These involve interactions of the transcription factors
Krüppel-like factor 1 (KLF1), B-cell lymphoma/leukemia 11A (BCL11A), GATA
binding protein 1 (GATA1), and others (Sankaran et al. 2011; Zhou et al. 2010).
14.4 Blood and Hematology 301

X-ray crystallographic studies demonstrate that oxyhemoglobin (R form) and

deoxygenated (T form) hemoglobin differ in conformation, oxyhemoglobin being
the most compact (Perutz 1964). For the interaction of globin chains with organic
phosphates, these conformational changes are critical (Perutz 1970). As noted ear-
lier, a crucial factor in determining O2 uptake in the lung or placenta and its delivery
to tissues is that of hemoglobin O2 affinity. In general, each mole of hemoglobin can
combine with 4 mol of oxygen (Scherrer and Bachofen 1972). By heme–heme inter-
action, as oxygen binds to a given heme group, it more readily binds to the other
heme groups. This mechanism gives the oxyhemoglobin saturation curve its sig-
moid shape, as first demonstrated by Christian Bohr (1855–1911) of the University
of Copenhagen (Bohr 1905). An equation that describes the oxyhemoglobin satura-
tion (or dissociation) curve was formulated by the 1922 Nobel laureate Archibald
Vivian Hill (1886–1977) of University College, London (Hill 1910) (for review of
this field see Astrup and Severinghaus 1986). In the adult, the alpha/beta chain
dimers bind allosteric cofactors such as organic phosphates, chloride ions, and pro-
tons which decrease the hemoglobin affinity. In the erythrocyte, that organic phos-
phate in greatest concentration is 2,3-diphosphoglycerate (2,3-DPG) (Benesch and
Benesch 1967; Chanutin and Curnish 1967; also called 2,3-bisphosphoglycerate).
By cross-linking the beta chains with stabilization of the quaternary structure of
deoxyhemoglobin, 2,3-DPG decreases hemoglobin O2 affinity. In fetal erythrocytes
with alpha/gamma chain dimers, such binding is minimized, resulting in increased
O2 affinity (Bauer et al. 1968, 1969; Delivoria-Papadopoulos et al. 1971a; Salhany
et al. 1971). During the latter third of gestation, the fetal erythrocyte concentration
of 2,3-DPG (called by some during the late 1960s and 1970s, the “Direct Path to
Grants”) rises to adult levels at term (~5 mM·L−1). During the first year of life this
increase continues, in concert with a decrease in hemoglobin F, before decreasing
again to adult levels (Delivoria-Papadopoulos et al. 1971b) (for review see Delivoria-
Papadopoulos and McGowan 2011).
It was in the beginning of the twentieth century that Karl Landsteiner (1868–
1943) discovered several isoagglutinins in human blood, that were capable of agglu-
tinating erythrocytes from another individual (Landsteiner 1900). Shortly thereafter,
Jan Janský (1873–1921) discovered that blood could be classified into four major
groups, O, A, B, and AB (Janský 1906/1907). Then, with the onset of World War II,
almost simultaneously both Philip Levine (1900–1987) and Rufus E. Stetson (1886–
1967) (Levine and Stetson 1939) and Landsteiner (Landsteiner and Wiener 1940;
Wiener and Peters 1940) discovered the Rh antigen. Later, with a development that
has contributed enormously to fetal medicine, Levine and coworkers first described
Rh incompatibility between a mother and her newborn infant (Levine et al. 1941).
Prior to this time, occasional transfusions of anemic newborns with erythroblas-
tosis fetalis were performed as a life-saving measure, but the results were variable.
With the discovery of the Rh factor, came an understanding that with Rh antigen on
the infant’s erythrocytes (inherited from the father but lacking in the mother), the
mother develops an antibody to the Rh antigen which crosses the placenta to destroy
fetal red blood cells. Soon Louis K. Diamond (1902–1999) (Fig. 14.4a) and col-
leagues, of Boston’s Children’s Medical Center and Lying-In Hospital developed
302 14 Further Developments in Fetal and Neonatal Physiology

Fig. 14.4 (a) Louis K. Diamond (1902–1999). (b) Sir Albert William Liley (1929–1983). (c)
Donald Henry Barron (1905–1993). (d) Frederick C. Battaglia, Giacomo Meschia, and Donald H.
Barron

the technique for treating such infants with exchange transfusion. Their initial report
was on 391 cases over the previous 4 year period (Diamond et al. 1951).
In an historic perspective Diamond recorded,
Thus, it was imperative to remove not only the infant’s antibody-coated Rh-positive red
cells but the plasma containing free anti-Rh gammaglobulin as well. A needle puncture of
the longitudinal sinus was too dangerous for this purpose; multiple peripheral veins and
arteries were too delicate for routine and lengthy procedures, but there was the umbilical
vein, invitingly large and patent. At first, we tried to enter it with large steel needles but
these could not be maintained in situ for long. Rubber catheters became a problem as well
as a risk, being too narrow and clot-promoting when blood was withdrawn. Fortuitously, we
learned about a plastic, nonwettable, nonirritating polyethylene catheter being used by …
our pediatric neurosurgeon. He had found that the plastic could be chemically sterilized and
reused, was nonirritating to the tissues, and retarded clotting … Preliminary in vitro and
animal implantation experiments were reassuring, and initial trials of umbilical vein cath-
eterization and blood exchange were successful.
(Diamond 1976, pp. 2–3)
14.4 Blood and Hematology 303

Diamond also noted,

The value of exchange transfusion as a therapeutic measure can be appreciated by the sta-
tistics; in the 1950s, with about 4 million births per year in the U.S., 1/200 infants would
have had EF [erythroblastosis fetalis] due to maternal Rh sensitization, a conservative esti-
mate of 20,000 infants/year. Before exchange transfusion became routine, mortality was
close to 50%, including deaths from kernicterus and its late complications. The new treat-
ment reduced this mortality to 10% or less, so that at least 8,000 newborn infants a year
were saved in the U.S. alone.
(Diamond 1976, p. 3)

At this time it became evident that spectrophotometry of red blood cell hemoly-
sis products in amniotic fluid could be useful in the diagnosis and prognosis of Rh
disease (Bevis 1952, 1956; Liley 1961). Albert William Liley (later Sir William)
(Fig. 14.4b) of the University of Auckland, originated the idea of intrauterine fetal
blood transfusion in the treatment of severe Rh disease (Liley 1963, 1964). Soon,
the validity of this approach soon was confirmed by others (Freda and Adamsons
1964). Beyond the treatment of Erythroblastosis fetalis per se, Liley’s studies dem-
onstrated that the pregnant uterus could be invaded without placing in jeopardy the
life of the fetus or the mother (Liley 1971a). In addition, Liley initiated the concept
of treating the fetus as a patient, initiating a “paradigm shift” in clinical obstetrics.
Liley later described this contribution.
The idea of fetal transfusion originated from two aspects of amniocentesis and one of these
was a mishap. First, because of the diagnostic precision of amniocentesis, it was possible
to define very clearly a group of babies affected so severely and so early by hemolytic
disease that were beyond the aid of conventional therapy. It was very frustrating to have to
put a diagnosis on a baby which was virtually a sentence of death and then sit back and
watch the baby die. Second, the mishap was due to the fact that occasionally at amniocen-
tesis in very severely affected babies – especially with a large anterior placenta to obscure
landmarks – I accidentally needled the distended fetal abdomen. Instead of getting deep
yellow, cloudy, amniotic fluid, I got brilliant, golden, clear fluid which was obviously
ascitic fluid; this windfall was easily confirmed by injection of contrast medium. Now this
had not been intended, and initially it was rather disconcerting, but it did not appear to
disturb the fetus – who was a write-off anyway. However, it occurred to me that if we could
needle the fetal peritoneum without even trying then perhaps we could do it deliberately
and put it to some good use.
… the possibility of using this route for transfusion was attractive and the only question
then was whether the fetus could take up sufficient cells rapidly enough to relieve anemia.
We were preparing to conduct some experiments in the occasional neonate who required
laparotomy (e.g., diaphragmatic hernias) to check uptake rates from the peritoneal cavity
but abandoned this preliminary project when a fortuitous visitor passed through Auckland
on her way home to the United Kingdom. This was a young English lady, aged 22, a geneti-
cist who had been working in Nigeria on her favorite topic of sickle cell disease. With her
she had some beautiful blood slides from neonates and infants, homozygous for HbS, who
had been given normal cells intraperitoneally. There were floods of normal cells in their
peripheral blood, and this was good enough evidence for us that cells could be taken up
from the peritoneum in massive quantity and at a relatively rapid rate.
We therefore went directly to the fetus. Both our staff and our isoimmunized patients
were quite familiar with needling pregnant uteri, the patients were no strangers to disap-
pointment and under no delusion regarding fetal prospects without treatment and, although
304 14 Further Developments in Fetal and Neonatal Physiology

a number of my senior colleagues did not really expect that this business would get off the
ground, at least they thought it was reasonable and worth a try – which was a great assur-
ance and encouragement.
(Liley 1971b, p. 303)

In another publication, Liley asked, is there a final solution to the problem? After
considering several alternatives, he concluded that we are engaged in a war that we
cannot win and from which we cannot disengage. Thus, he suggested that it seems
both premature and arrogant to speak of the conquest of haemolytic disease (Green
1985). As noted, some of the historical aspects of exchange transfusion have been
reviewed (Diamond 1976, 1983). Within a decade direct transfusion into the umbili-
cal vessels was being performed (Berkowitz et al. 1986a, b). The importance of
Liley’s work lies in it marking the beginning of fetal medicine, for within several
years, cells from amniotic fluid samples would be used for chromosomal analysis to
determine the absence or presence of genetic disorders, and numerous other condi-
tions could be diagnosed and treated.
Prevention of Rh sensitization in the fetus and newborn then resulted from the
work of two groups of investigators who independently conceived and developed
the idea. Vincent J. Freda (1927–2003) and John G. Gorman of Columbia
University with William Pollack of the Ortho Research Foundation started with
the known concept that passive immunity, under proper conditions, can block
active immunization (Freda and Gorman 1962). These workers first developed
the specialized hyperimmune anti-Rh gamma-globulin (RhoGAM) preparation
for providing passive immunity which is now used worldwide (Mittendorf and
Williams 1991). In Rh-negative male volunteers, they then tested their hypothe-
sis by intravenous administration of Rh-positive erythrocytes followed by injec-
tions of the Rh antibody (Freda et al. 1964; Gorman et al. 1964). The authors
concluded,
To sum up, we are cautiously optimistic that prevention of erythroblastosis is possible. We
feel that the directions that must be followed are now clear. However, there remains a vast
amount of applied research to be done before preventive therapy of hemolytic disease of the
newborn can become a practical reality. This must be vigorously pursued.
(Gorman et al. 1964, p. 549)

Subsequently, these investigators instituted a trial of passive immunization in

Rh-negative mothers at risk and found a similar protective effect (Freda et al. 1965,
1966). Concurrently with the New York group, Ronald Finn (1930–2004) and Cyril
Astley Clarke (later Sir Cyril; 1907–2000) and their associates of Liverpool,
England, demonstrated the protective effect of Rh-antiserum in blocking sensitiza-
tion (Clarke and Finn 1977; Finn et al. 1961). With other groups throughout the
world, they established the clinical effectiveness of this prophylaxis. Paradoxically,
Dr. Freda’s original application for a grant to support this monumental research was
rejected as unfeasible. Both Freda and Finn, with their colleagues, have written
accounts of their achievements (Finn et al. 1977; Freda et al. 1977). In 1980, Freda,
Gorman and Pollack with Sir Cyril Clarke and Finn shared the Albert Lasker
Clinical Medical Research Award.
14.5 Hyperbilirubinemia and Kernicterus in the Fetus and Newborn 305

14.5 Hyperbilirubinemia and Kernicterus in the Fetus

and Newborn

In association with Rh disease and other hemoglobinopathies, a critical problem,

particularly among premature newborns, was hyperbilirubinemia with the develop-
ment of kernicterus which may be toxic to brain cells. Kernicterus (German kern,
kernel nucleus, Greek okterus, jaundice) is staining of and damage to brain centers,
particularly the basal ganglia, by unconjugated, indirect bilirubin, e.g., that not
bound to plasma albumin. In the newborn infant this may occur as a consequence of
polycythemia with lysis of erythrocytes, or the congenital defect in bilirubin metab-
olism, hereditary hyperbilirubinemia, Crigler–Najjar syndrome type I. Kernicterus
also may be a consequence of Rh incompatibility between mother and fetus, with
hemolysis of fetal erythrocytes and release of unconjugated bilirubin into the circu-
lation. Christian Georg Schmorl (1861–1932), pathologist at the University of
Dresden, coined the term kernicterus (Schmorl 1904); however, the condition itself
had been described by several previous workers (see Hansen 2000; Sourkes 1997).
In the “Pre-intensive care” era (e.g., prior to ~1965), newborns, who in general
were more than 28 weeks gestation and weighed more than 1,250 g, often developed
hyperbilirubinemia with kernicterus, not always as a consequence of hemolytic
disease. Initially, these infants were believed not to develop this pathology unless
the serum bilirubin level exceeded 18–20 mg·dL−1, and the only effective therapy
was exchange transfusion (Lucey 1960). From this time to ~1980, the era of “Early
Intensive Care,” emerging technologies and sub-specialization with the develop-
ment of neonatology, was associated with survival of infants less than 28 weeks
gestation who weighed less than 1,000 g. With smaller and smaller preemies surviv-
ing, these years saw many in which kernicterus developed at relatively low bilirubin
levels (10+ mg·dL−1).
An important contribution during this era was the serendipitous observation that
the introduction of a regimen of administering antibiotics to premature infants dur-
ing the first 5 days of life could result in a higher death rate with an increased inci-
dence of kernicterus (Andersen et al. 1956). With the mid-century development and
introduction of new antibiotics, several workers recommended that their administra-
tion to premature newborns would lower mortality rates. While believing this to be
a reasonable idea, to help provide statistical evidence for this regimen William
Aaron Silverman (1917–2004) and colleagues at Columbia University commenced
a clinical trial to compare the results of the proposed new therapy (oxytetracycline)
with that of an “established regimen” (penicillin plus sulfisoxazole). To demonstrate
a 25 % reduction in mortality they calculated that 100 infants in each treatment
group would be required. Concurrently, for another trial, bilirubin levels in the
infant’s blood were being measured (Andersen et al. 1956). Silverman has recorded
that part way through the trial his colleagues informed him that most of the kernic-
terus was occurring in the penicillin/sulfisoxazole group.
I was astounded by this announcement and quickly “peeked” at the outcome in 192 infants
who had been enrolled thus far. The findings were so shocking that the trial was stopped.
306 14 Further Developments in Fetal and Neonatal Physiology

The fact that the formal trial had “saved” half of the infants from exposure to the unsus-
pected hazards of the accepted treatments was undeniable, but this experience made it clear
that the fixed-sample-size design must be modified to provide protection against unex-
pected effects in clinical studies.
(Silverman 1979, p. 3)

Regarding the statistical method Silverman observed,

Naively, I thought that suspicion and antipathy toward the use of statistics in medicine (by
no means rare at the time) would surely change. The power and inherent safety of scientific
method, embodied in the small-sample techniques that had been developed by R.A. Fisher,
had been so well documented in agricultural research and were so well accepted in preclini-
cal studies, I was certain that medicine’s irrational resistance could not last for long. After
a quarter of a century of observing innumerable examples of our failure to learn from past
disasters, I can see that my early optimism was completely misguided.
(Silverman 1979, p. 3)

Subsequent studies demonstrated that sulfisoxazole displaced bilirubin from its albu-
min binding site, thus permitting the unbound bilirubin to diffuse into the brain (Odell
1959). As is now appreciated, there is no precise bilirubin threshold, as many factors
including: degree of prematurity, hypoxia, acidosis, hypothermia, hypoglycemia,
hypoproteinemia, sepsis, and certain pharmaceutical agents, either in isolation or in
combination, can augment susceptibility to brain damage (Ackerman 1970; Ackerman
et al. 1970; Gartner et al. 1970; Hansen 1993; Keenan et al. 1972; Lucey 1972a).
Also during this time, the therapeutic value of phototherapy, which had been
reported from Britain (Cremer et al. 1958), was recognized (Ives 1992; Lucey 1960,
1969, 1974, 1977; Lucey et al. 1968), along with more aggressive exchange transfu-
sion. Ever the pediatric provocateur, the “father” of “Lucey Lights” has raised a
number of questions and considered controversial issues regarding this therapy
(Lucey 1972b, 1974). From the 1980s onward, the era of “Intense Intensive Care,”
with discontinuation in NICUs of the antiseptic benzyl alcohol, the incidence of
hyperbilirubinemic encephalopathy in premature newborns virtually disappeared
(Watchko and Oski 1992). The American Academy of Pediatrics has published
guidelines on the management of hyperbilirubinemia (American Academy of
Pediatrics Subcommittee on Hyperbilirubinemia 2004). Nonetheless, despite being
largely of historical interest, many questions remain about the basic pathophysiol-
ogy and neuropathology of this devastating disorder (Newman and Maisels 1992).
For his many contributions, in 2010 Lucey was recipient of the John Howland
Award of the American Pediatric Society (Lucey 2010).

14.6 Immunology

A remarkable aspect of reproduction is that a pregnant woman with a functional

immune system can succeed in maintaining a semiallogenic fetus to term without
immunologic rejection. Thus, a critical question is by what mechanism does the
mother not reject the normally developing embryo/fetus? During the 1950s and 1960s
14.6 Immunology 307

several groups began to explore the ontogeny of fetal immune tolerance. Initially, this
work was stimulated by the idea that because the maternal organism does not reject
the fetal allograph, it must exist in an immunologic deficient state. Over several
decades this was replaced by a more contemporary view of a genetically programmed
sequence of immunologic maturation that proceeds in an orderly manner (Hayward
1978; Miller 1966). For instance, it had been demonstrated that at 110–117 dpc the
sheep fetus rejected maternal skin grafts (Schinckel and Ferguson 1953). In addition,
on the basis of experiments in mice and chickens, Rupert Everett Billingham (1921–
2002) and coworkers at the University of London, advanced the concept that “actively
acquired immunologic tolerance” in the mouse develops in response to fetal exposure
of foreign antigens (Billingham et al. 1953). Rather than a placental “barrier,” several
studies demonstrated the facility with which gamma globulins cross the placenta
from mother to fetus (Bangham 1961; Brambell 1961). Subsequently, Arthur Matthew
Silverstein and colleagues at the Johns Hopkins University reported immunologic
rejection in the fetal lamb as early as 77 dpc (Silverstein et al. 1964). Even removal of
the fetal thymus, which was believed to release cellular or hormonal immunologic
factors, failed to suppress antibody formation (Silverstein and Kraner 1965).
Silverstein also demonstrated considerable temporal differences in the development
of the immune system among several species, e.g., that immunologic competence to
various antigens does not develop simultaneously, but rather at different times during
gestation (Silverstein 1964, 2009). A study that provides insights into the mechanism
of maternal-fetal tolerance suggests that previous ideas have been overly simplistic.
Specifically, the authors propose that a subset of CD4+ helper T cells, so called periph-
eral (extrathymic) T cells, act through sophisticated molecular mechanisms to enforce
maternal-fetal tolerance (Samstein et al. 2012).
By what mechanisms does the fetus develop its immunologic tolerance? A num-
ber of reports have demonstrated transfer of proteins, cells, and other foreign anti-
gens across the placenta from mother to fetus, and vice versa. For instance, the
placenta actively transports the small IgG immunoglobulins from the maternal to
the fetal circulations. In contrast, the maternal IgA, IgE, and IgM antibodies do not
cross to the fetus in appreciable amounts, thus the newborn infant has low levels of
these immunoglobulins (Kane and Acquah 2009; Palmeira et al. 2012). Maternal
cells also may cross the placenta and engraft into human fetal tissues, resulting in
“maternal microchimerism” (Adams and Nelson 2004). The mechanisms by which
the fetal immune system recognizes and responds to such antigens is unclear.
A novel concept of fetal tolerance, is that maternal cells (perhaps pluripotent stem
cells that have crossed the placental barrier and not been eliminated by fetal natural
killer cells), “instruct” activated T lymphocytes (regulator T cells) of the fetus to
become tolerant of self antigens and reactive against those that are foreign, thereby
suppressing fetal immune responses (Hayward 1978; Mold et al. 2008). In the
human fetus, lymphocytes that can recognize antigen appear as early as 12 weeks
gestation. Multiple factors influence responsiveness of these cells, enhancing their
capacity to make IgM antibody, including regulation of T lymphocytes, deficiency
of number or function of macrophages, and altered number or function of B lym-
phocytes (Hayward 1978). For both the fetus and newborn, the complex set of
308 14 Further Developments in Fetal and Neonatal Physiology

immunologic demands in response to potentially harmful inflammatory immune

responses, and protection against infection both in utero and following birth, pres-
ent challenges of enormous scope (Levy 2007; Solomon 1971). Particularly sober-
ing, is the realization of how much we have to learn regarding tolerogenic versus
immunogenic forms of microchimerism, fetal-maternal immune mechanisms, and
the mechanisms of immunologic responses in the newborn (Burlingham 2009).

14.7 Chronic Catheterization of the Fetus

In the mid-1960s, a technical advance was made that would present a “sea change”
to the study of fetal physiology and related functions. Since the time of Paul Zweifel
and the late nineteenth century investigators, an issue in the study of the ruminant or
other large mammalian fetus in utero, was the necessity for the fetus, with the ewe,
to be anesthetized for performance of the required studies. This resulted in a bio-
logic Heisenberg (after Werner Heisenberg) uncertainty principle, e.g., that in per-
forming a given measurement one changed the value of that variable being measured.
For fetal physiology, these measurements under anesthesia were “acute,” rather than
reflecting the true undisturbed steady-state conditions of intrauterine existence. In
1965, the Yale group, led by Donald H. Barron and Giacomo Meschia (Fig. 14.4c, d;
Fig. 14.5c) reported on their use of plastic catheters, chronically implanted in the
fetal vasculature and other sites. With this technique one could study blood gas val-
ues and other variables for several weeks following recovery from the anesthesia and
surgery required for their implantation. Importantly, Meschia and colleagues dem-
onstrated for the first time that, contrary to the accepted belief (as had been “demon-
strated” by Barcroft) that fetal arterial PO2 and [HbO2] decreased significantly
near-term, this was not the case, but rather these values remained constant (Meschia
et al. 1965). This breakthrough, not appreciated by many for a decade or more, revo-
lutionized study of the developing fetus in a truly physiologic state. This innovation
by Meschia, Barron, and colleagues, is a worthy example of the manner in which a
methodologic advance can contribute to a conceptual “paradigm shift” in the course
of science. Meschia has written on some aspects of this contribution (Meschia 2006).
Following his retirement from Yale, Barron accepted the Julius Wayne Reitz
(1908–1993) Chair of Reproductive Biology at the University of Florida, Gainesville,
where he continued studies on uterine and fetal blood flow and oxygen consump-
tion. Barron liked to remind students that “science begins with a question while
technology begins with a task.” He also stressed that a carefully conceived hypoth-
esis could be tested effectively in many ways. Pondering alternative approaches to
the design of an experiment, he taught, “… was not only valuable intellectually, but
often revealed more elegant, robust, and efficient methods of answering important,
complex questions. Alternatives need not be obstacles” (Bartol 2000, p. 6). In regard
to placing problems in their proper perspective, Barron noted, “I concluded a long
time ago that I had plenty of information, but little knowledge concerning it.” As a
pedagogue he observed, “Good teaching consists in asking a question the student
14.7 Chronic Catheterization of the Fetus 309

feels compelled to answer for himself” (Johnson and Friedrich 1985). Regarding his
rejection of plans for retirement, he observed “… I feel like a boy who gets paid to
go fishing,” and “as long as it’s fun and I can still play the game … I’ll find some
aspect to study” (Anonymous 1981, pp. 15–16).
From the University of British Columbia, the 16th Baron of Corcomroe, Anthony
Manning Perks, recalled memories of Dr. “B” at Gainesville.
My post in Zoology also offered me freedom to go down to work with … Sidney Cassin, at
the University of Florida, where I had been the first Postdoctoral Fellow (they say that when
I die, they will stuff me, and put me in a glass case, next to the first Graduate Student!). It was
through Sid that I first met Dr. Donald Barron, Sir Joseph Barcroft’s closest co-worker, to
whom he dedicated his pioneer book. Dr. Barron was retired from Yale, and held in great
honour, in the Ob/Gyn Department in Florida, down on the 3rd Floor. Sid introduced me to
Barron as having worked with Geoffrey. There was a brief hesitation, but slowly our relation-
ship blossomed, especially when Barron realized that I had started my career in Cambridge,
in Charles Darwin’s old college, Christ’s Church. It soon became clear how much Barron
missed Cambridge, and regretted leaving it, we often shared memories of the many eccentric
professors (like ourselves!), who we had both known. From that point on, Barron and I
became close friends. On one occasion, Geoffrey visited Florida, and Sidney and I took him
down to talk to Barron; Geoffrey listened attentively to Barron, who was still fascinated by the
placenta (although now without a lab). It was clear that there was great respect between the
two – and yet a feeling of distance. It was only later I was told (so far as I know, accurately)
that when the Nuffield Institute first opened, Barron, with his huge accomplishments in fetal
physiology, had applied for the Directorship. However, Oxford chose its own, and gave the
job to Geoffrey, a bright, but less experienced young man. It was then that I realized the reason
for Barron’s reticence when we first met! I was a Dawes-man! So happy I overcame this.
Later, there were other experiences involving Dr. Barron. When I was writing a review, I
asked him whether he could give me the original reference to William Harvey’s “De
Generatione…” Barron thought for a minute, then said, “I think I can help you”. Next day, he
came shuffling slowly along the long corridor, with a book in his hand. “This is what you
want. I’m sorry. This is the Frankfurt printing; I could not afford the earlier one”. It was the
original book!!! From the 16 hundreds! Barron’s books came into my life a second time. One
day I went down from Sid’s lab in Florida, after surgery, to get a cup of coffee. As I passed
the library, I saw some students pawing through a pile of books, free, and left sitting in the hot
sun, in the courtyard. It was after Barron had, sadly, died. I went over to look, and saw one of
the students throw down an old, almost derelict, brown book. I picked it up, and realized that
these “discards” were Barron’s old books. The book thrown down was not only the first book
on Fetal Physiology, Barcroft’s “Researches on Fetal Life”, but it was the first book, the proof
copy, occasionally annotated by Barcroft himself, and printed on irregular browned sheets of
wartime paper. I grabbed it, together with Barron’s own 1977 reprint, and a pile of books of
medical history, such as the life of Galen. I still have them all, and treasure them.
(Letter from AMP to LDL, 23 April 2010)

Later Perks wrote,

In addition, your recent letter started me thinking more about Dr. Barron. I gave a number
of memories in my previous letter, but more came streaming back over the weekend…
Their only merit is that I knew Barron well during his late retirement years, in Florida, when
he seemed to be a little on his own.
Many mornings, on my visits to Gainesville, as I drove into the Medical School, along
13th Avenue, I would overtake Barron on his large, heavy bicycle. He would be stopped at
the side of the road, dressed in his usual white pith-helmet, looking for all the world like a
British colonel in the Indian Army of Victorian times. His bicycle would be leaning on a
310 14 Further Developments in Fetal and Neonatal Physiology

fence, while he himself was engrossed in writing on a notepad. Apparently, whenever a new
idea occurred to him he stopped wherever he was, even in the countryside, and put it down,
before he lost it. Once in his office, he would put on a long, white lab-coat, just as if he still
had a lab – I think because he really missed having one. I do the same, not to emulate him,
but for the same reason! He would always wear the same lab coat to seminars, the only one
to do so, and sit towards the back, near a beautiful painting of himself in his gorgeous
Cambridge Sc.D. robes …
I would often go to his office, and talk to him about his current interests, often historical
ones: I shared these interests, but the busy clinicians had neither the time nor the interest for
such things. He was much on his own, and shy in social settings. He had taken a great inter-
est in such people as Sidney Ringer [(1835–1910)], and I always encouraged him to publish
what he had found – but he never did, and much was lost. Once he said that he had submit-
ted a paper to an historical journal, but when it was turned down, never did again. I wonder
whether the referees ever realized that he had known many of these people, famous in the
history of medicine. What a loss! He would often talk of his summer visits to the
“Krakenhaus” where Sigmund Freud [(1856–1939)] had worked. He would disappear into
the library until evening, and then meet his wife (who he always referred to as “Mrs. B”) on
a certain bench, in a certain park, at a certain time: they seemed to have a very ordered life,
but a very close one.
(Letter from AMP to LDL, 26 April 2010)

14.8 Cardiovascular Physiology

Shortly following the introduction of chronic catheterization of the ovine fetus,

Abraham Morris Rudolph and Michael A. Heymann (Fig. 14.5a), at the University
of California, San Francisco, introduced the use of microspheres, labeled with various
radioactive nuclides, to quantitate cardiac output and the regional distribution of
blood flow to the brain, heart, and other organs in the fetus (Rudolph and Heymann
1967). Again, because microspheres did not alter the course of blood flow, and there
was no significant recirculation, this methodological development changed the
course of cardiovascular research at the organ level, not only the fetus, but also that
for the newborn infant as well as adult (Heymann et al. 1977; Rudolph 1985). In
further contributions with this methodology, Rudolph and colleagues reported on
many aspects of fetal cardiac function, and blood flow in the umbilical vessels, the
superior and inferior vena cavae, and the vascular shunts including the ductus arte-
riosus (Hoffman 2002; Rudolph 1996; Rudolph and Heymann 1970), as well as the
responses to hypoxia and other stress (Itskovitz et al. 1982, 1987, 1991; Rudolph
1984). In an essay, “The fetus at Everest or Death Valley,” Rudolph correctly dis-
missed the concept that the fetus is at “Mt Everest in utero.” Yet, despite the fact that
the fetal basal temperature exceeds that of the mother by only 0.5 °C (in the sheep;
Lotgering et al. 1983), he compared it to being at Death Valley (Rudolph 1989). The
justification for this latter metaphor in unclear when the in utero existence in a
rather watery milieu is hardly that of a scorchingly hot, semi-arid desert. Clinically
and importantly, Heymann, Rudolph, and colleagues used the prostaglandin synthe-
sis inhibitor indomethacin to close the ductus arteriosus in premature infants
14.8 Cardiovascular Physiology 311

Fig. 14.5 (a) Michael Heymann and Abraham Rudolph (ca. 1980). (b) Nicholas S. Assali (1916–
2004). (c) Giacomo Meschia. (d) Raymond D. Gilbert

(Heymann et al. 1976), and prostacyclin E1 to maintain potency of the ductus in

infants with pulmonary atresia (Clyman et al. 1978; Heymann and Rudolph 1977).
As noted, since the beginnings of fetal physiology a critical issue has been the
extent to which functions in the exteriorized fetus may be regarded as truly physi-
ologic, as compared to that of the relatively undisturbed state in utero. The earliest
such comparison of the chronically catheterized in utero fetus with that of acute
fetal exteriorization under epidural or general anesthesia ex utero, demonstrated
significantly increased vascular resistance with a 37 % decrease in umbilical blood
flow, and a small, but significant, increase in umbilical venous O2 tension (Heymann
and Rudolph 1967), presumably associated with prolonged transit time in the pla-
cental exchange area. Later, Dawes would argue for the need for, and validity of,
both approaches (Dawes 1984, p. 262). In a subsequent report, Rudolph considered
the continued need for studies of organ-based cardiophysiologic systems in a world
312 14 Further Developments in Fetal and Neonatal Physiology

in which cellular and molecular biology constitute the major emphasis. Here, he
argued for the need for continued exploration of the mechanisms of cardiovascular
responses to hypoxia, the role of mechanical loading on myocardial growth, and the
effect of congenital heart disease with altered circulating patterns on cardiovascular
growth and development (Rudolph 1996).
At the University of California, Los Angeles, Nicholas S. Assali (Fig. 14.5b) was
another leader in investigation of fetal and maternal physiology. One of the develop-
ers of the electromagnetic flowmeter, Assali pioneered techniques for the measure-
ment of uterine blood flow and utero-placental-fetal metabolism (Assali et al. 1960;
Ladner et al. 1970), and studied the development of autonomic and neurohumoral
regulation of fetal and neonatal cardiovascular function (Assali et al. 1969, 1970,
1977, 1978; Nuwayhid et al. 1975; Woods et al. 1977). With use of their flowmeter,
this group also presented quantitative data showing the decrease in ductus arterio-
sus blood flow to almost zero following ventilating the fetal lungs with oxygen, the
flow returning to normal when the inspired gas was switched to nitrogen. In these
studies this group also quantified in the fetus the relatively low vascular resistance
and high cardiac output, presumably to compensate for its relative low O2 content
(Assali and Brinkmann 1972; Assali et al. 1970). In general, the studies of this
group were in anesthetized ewes with the fetus either marsupialized to the uterine
and abdominal walls or in utero. In comparing these experimental animals to those
that were chronically instrumented and unanesthetized, the chief physiologic differ-
ences observed were that in the later maternal arterial blood pressure was lower as
was the arterial PO2, presumably because the acute group were artificially ventilated.
Assali maintained that for the fetus, the physiologic cardiovascular responses were
similar (Assali et al. 1974). As an aside, one study reported that as a consequence of
chronic instrumentation, fetal body weight and thymus weights were decreased 15
and 27 %, respectively, while the liver to body weight ratio was increased 24 %
(Clark et al. 1990).
In other studies of fetal cardiovascular function, Raymond Gilbert (Fig. 14.5d),
at Loma Linda University, demonstrated that the relatively high cardiac output
observed in the fetus (several times that of adult) is achieved by two mechanisms.
One, both right and left ventricles eject blood into the aorta. Two, both ventricles
are working at near maximum capacity; that is, they are at the top of their respec-
tive cardiac function curves (Gilbert 1980). Because the ventricles are quite sensi-
tive to afterload, e.g., arterial blood pressure (Gilbert 1982), when the fetal
cardiovascular system is stressed (as with hypoxia of a few hours duration), car-
diac output either remains unchanged or decreases (Gilbert 1998). With longer
term hypoxia of several months, fetal cardiac output is decreased by ~25 % because
of reduced function of both ventricles (Kamitomo et al. 1992, 1994). With acute
hypoxia, fetal cardiac output is redistributed to the brain, heart, and adrenal glands
at the expense of the rest of the body (Peeters et al. 1979), and with long-term
hypoxia this creates the potential for asymmetric growth restriction (Kamitomo
et al. 1993). The reduced myocardial function is brought about by a decreased
myofibrillar response to intracellular calcium concentration, which probably is
mediated by reduced myofibrillar Mg2-activated ATPase (Browne et al. 1997a, b).
References 313

In addition, the coronary vasculature of the long-term hypoxic fetus exhibits

reduced contractile responses to extracellular K+ and to intracellular calcium con-
centrations. The reduced coronary vascular contractile response to intracellular
calcium is mediated completely by changes in calcium sensitivity through the Rho
kinase pathway (Maruko et al. 2009).

14.9 Related Fields of Research

Many organ systems are not considered in this review. Thus, quite obviously there
are many topics in fetal–newborn physiology the history of which are worth study.
For instance, blood flow to the gravid uterus is a major consideration in terms of
fetal homeostasis and well-being. Several recent reviews place this field in perspec-
tive (Paradis and Zhang 2013; Pastore et al. 2012; Sen and Chaudhuri 2013;
Thornburg and Louey 2013; Xiao et al. 2010; Zhu et al. 2013). A related area of
fetal physiology of great relevance is that of amniotic fluid metabolism, rates of
turnover, and regulation (Brace et al. 2004; Jellyman et al. 2009; Robertson et al.
2009). Yet another is the circadian periodicity of the developing fetus, and the fact
that for its circadian rhythmicity the fetus is dependent upon maternal melatonin
which crosses the placenta (Yellon and Longo 1987, 1988).

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Chapter 15
Additional Clinical Aspects
of Developmental Physiology

The woman about to become a mother, or with her newborn

infant upon her bosom, should be the object of trembling care
and sympathy wherever she bears her tender burden or stretches
her aching limbs … God forbid that any member of the profession
to which she trusts her life, doubly precious at that eventful
period, should hazard it negligently, unadvisedly, or selfishly.
(Oliver Wendell Holmes 1842/1843, p. 503)

15.1 Preterm Birth and Neonatal Intensive Care

A major public health issue is that of preterm birth, which occurs in 10–12 % of
pregnancies in the USA, an incidence which appears to be rising inexorably.
Importantly, this complication of pregnancy accounts for about 75 % of perinatal
mortality, and can be associated with several serious long-term developmental and
health issues for the infant who survives. As noted earlier, preterm birth is defined
as that <37 weeks gestation, while extremely preterm birth is that <33 weeks gesta-
tion (Reece and Hobbins 2007). Appropriate for gestational age preterm infants
must be distinguished from small for gestational age infants, defined as ≤10 percen-
tile (Zhang et al. 2010), although it is recognized that small infants are not necessar-
ily growth restricted, and those with growth restriction are not necessarily small
(Bhide 2011; Zhang et al. 2010). In part, a consequence of maternal and/or fetal
infection (Abramowicz and Kass 1966; Romero et al. 1988), preterm birth has many
causes, and a more clear understanding of the mechanisms of this scourge is essen-
tial to its amelioration. Also as noted earlier, several aspects of the basis for antena-
tal steroid therapy for pulmonary development have been established (Ballard and
Ballard 1995; Ballard et al. 1980). Nonetheless, a considerable body of evidence
supports the value of this modality in lessening infant morbidity and mortality
(Bonanno and Wapner 2009) and a number of considerations remain to be resolved
such as the ideal drug, dosage regimen, indications for retreatment, and so forth.
During the first half of the twentieth century premature and other newborn infants
were under the care of nursery nurses, midwives, and obstetricians. There were few
incubators, no advanced technology, and no rooming-in. Although pediatrics was a
well-defined specialty, emphasis was on the care of older children, and few had
experience with the care of newborn infants, much less those that are premature
(Cone 1979). Beginning in the late 1950s and during the 1960s, a milestone of
extreme importance was the organization of neonatal intensive care units (NICUs)

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 327
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_15, © American Physiological Society 2013
328 15 Additional Clinical Aspects of Developmental Physiology

at major medical centers. Quite obviously, the salvage of premature infants is inter-
twined with that of the development of NICUs and their enlightened utilization. In
turn, this critical advance depended upon new insights and understanding of the
basic physiological concepts being discovered in respect to the lung, the heart, tem-
perature regulation, and other considerations. Of vital importance, the establish-
ment of NICUs with increased sophistication, and with widespread access based on
the existence of regionalization, has allowed the development of a national network
that is saving the lives of many premature or otherwise ill newborns who in former
times would have died soon after birth. Thus, a brief review of some aspects of these
symbiotic developments may be appropriate.
Several authors have presented an historical perspective on the origin and devel-
opment of neonatal care and the subspecialty of neonatology (Cone 1983, 1985;
Desmond 1998; Dunn 1998; Philip 2005). Over the centuries, a number of works
have included aspects of pediatrics and care of the newborn (Radbill 1971), and
only a brief survey will be presented here. An eighteenth century milestone in this
regard, for its innovation and attempt to correct erroneous concepts, was the 1748
letter to one of the governors of the recently established Foundling Hospital,
London. In this, William Cadogan (1711–1797) of Bristol, laid down rules on the
nursing, feeding, and clothing of infants, particularly those that were puny (Cadogan
1748). This essay was of great importance, as in eighteenth century England, infant
welfare was much neglected through the ignorance of mothers and midwives as well
as physicians, and “foundlings,” abandoned infants with their excessive mortality,
were a common feature of life. Established by Royal Charter in 1739 and formally
opened 2 years later, the Foundling Hospital was dedicated to the education and
support of these deserted infants and young children. Cadogan wrote his essay with
the hope that the Hospital would “… be a Means not only of preventing the Murder
of many, but of saving more by introducing a more reasonable and more natural
Method of Nursing” (Cadogan 1748, p. 3). Called by some “the Father of Child
Care” (Rendle-Short and Rendle-Short 1966), Cadogan’s pamphlet of only 34 pages
had a much wider influence than its size might suggest. He presented a scathing
view of caretakers, who because of traditional prejudices “… are capitally mistaken
in their management of children,” their care having “… no real Foundation in
nature” (p. 4). In establishing his case, Cadogan referred to the London Bills of
Mortality in which one may observe that, “… almost Half the Number of those, who
fill up that black list, die under 5 Years of Age” (p. 6). As examples of mismanage-
ment, he noted that an infant’s head would be bandaged tightly (to improve its shape
and to aid in closure of the anterior fontanelle), and that infants would be stuffed
into tight flannel and its limbs swathed with unyielding wrappers (to prevent bowing
of the legs and spinal deformities, which probably occurred as a result of rickets).
Counter to these practices, Cadogan recommended loose clothing and freedom of
movement, as well as exposing the infants to fresh air so that they would not become
a “… Hot-bed Plant” (p. 9). Also of importance, Cadogan advocated breastfeeding
infants by the mother rather than a wet nurse, and delaying until several months of
age feeding with simple and light solid food rather than “overfeeding” them early
with “heavy” foods (Rendle-Short 1960). Six years following the appearance of this
15.1 Preterm Birth and Neonatal Intensive Care 329

Fig. 15.1 (a) Etienne Stéphane Tarnier (1828–1897). (b) Pierre Budin (1846–1907). (c) Joseph
Bolivar DeLee (1869–1942). (d) Robert Usher (1929–2006)

work and his move to London, Cadogan was elected a physician of the Foundling
Hospital (Munk 1861).
In the early 1800s, recognition of the special needs of premature infants stim-
ulated Johann Georg von Ruehl (1769–1846) of St. Petersburg, Russia to invent
an incubator for newborns (Cone 1981). Others also credit Etienne Stéphane
Tarnier (1828–1897), (Fig. 15.1a) one of the great accoucheurs and chief of
obstetrics at L’Hôpital Maternité, Paris, with pioneering care of the premature
infant. In about 1880, Tarnier introduced the use of an incubator he modeled
upon that used for chicks. By 1893 the unit at the Maternité was expanded into a
Pavillion des Enfants Debiles [Pavillion of Weakling Infants] with a dozen incu-
bators (Henry 1898; Pinard 1909; Toubas and Nelson 2002). Following estab-
lishment of crèches [day nurseries] for the care of infants of the increasing
numbers of women who worked in factories, in 1876 the Sociéte de Allaitement
330 15 Additional Clinical Aspects of Developmental Physiology

Maternalle [Society for the promotion of breast-feeding by mothers] was founded

to provide homes for expectant mothers during the last weeks of pregnancy, prior
to their entering a maternity hospital for confinement. To encourage breast feed-
ing, for up to a year financial and other assistance was given to mothers who
nursed their infants. Importantly, Pierre Constant Budin (1846–1907) (Fig. 15.1b),
a student of Tarnier who became chief obstetrician at the Hôpital de la Charité
(1882) and at L’Hôpital Maternité (1895), recognized that a major factor in
infant mortality was the lack of proper care and feeding of those born prema-
turely. Budin initiated what became known as the puériculture [child care] move-
ment, with the development of centers for Consultation de Nourrissons [newborn
infant consultation] (Budin 1900). Mothers who delivered in maternity hospitals
were encouraged to return at regular intervals so that their infant could be
weighed and examined, and often the mother received an honorarium based on
the baby’s progress and fitness (McCleary 1933).
In the provinces, with less access to specialized maternity hospitals, the French
infant welfare movement took a different form. Here centers for Goutte de Lait
[drops of milk] were dedicated to supporting breast-feeding, providing clean, steril-
ized milk for those bottle-fed, and weighing the infants to follow their development
and well being. To emphasize that cow’s milk constituted a poor substitute for
mother’s milk, their motto Faute de mieux [for lack of the best] was affixed to the
baskets containing bottled cow’s milk for those mothers who did not breast feed. In
general, the mothers would return weekly to have their infants weighed and exam-
ined, and every effort was made to promote the child’s well-being. A British senior
medical officer in the UK Ministry of Health, George Frederick McCleary (1872–
1962), has given a detailed history of the early years of the infant welfare movement
in France, Great Britain, and America (McCleary 1933). Budin promoted the idea
(“Budin’s rule”) that the bottle-fed newborn should be given milk daily equal to no
more than one-tenth its body weight (Budin 1900; Toubas 1992), and did much to
promote the education of mothers in child care. In his essay “Incubator-baby side
shows,” William Silverman described the manner in which, beginning in the late
nineteenth century, incubators with premature infants were featured at national and
international exhibitions (Silverman 1979, 1980a). In 1891, a leader in this crusade,
Alexandre Lion of Nice, established an infant charity in Paris, and several other cit-
ies, in which preemies were displayed in a couveuse [hatchery or incubator] of his
design. A British magazine article of the time featured in some detail, photographs
and description of Lion’s Oeuvre Maternalle des Couveuses D’enfants [The baby
infant charity] in Paris (Smith 1896).
In turn, Budin’s protégé Martin Arthur Couney (ca. 1860–1950) in 1896 (the
same year as Lion, and perhaps under Lion’s direction) exhibited their latest incu-
bator with living premature babies, at the Berliner Gewerbe Ausstellung [World
Trade Exposition] in Berlin. This exhibit, the Kinderbrotonstalt [child hatchery] of
six preemies, each in an individual incubator, drew considerable attention, its popu-
larity being a forerunner of many similar demonstrations to follow. These included
the 1897 Victorian Era Exhibition in London (at which, because British infants
were not allowed to be shown, premature infants were brought from France), the
15.1 Preterm Birth and Neonatal Intensive Care 331

1898 Trans-Mississippi Exhibition in Omaha, NB, the 1900 Pan-American

Exhibition in Buffalo, NY, the 1904 Louisiana Purchase Exhibition in St. Louis,
MO, the 1915 Panama Pacific International Exhibition in San Francisco, and the
1930 Chicago World’s Fair, and others (Baker 2008; Raju 2006; Silverman 1979;
Winks et al. 1997).
In America, it was Joseph Bolivar De Lee (1869–1942) (Fig. 15.1c) of the
Chicago Lying-in Hospital, and a leader in the emergence of obstetrics as an
academic discipline (De Lee 1913), who in 1900 established an incubator station
at the Lying-in. This included an ambulance service with an incubator in which
to transport babies from where they were delivered at home to the hospital.
Another important figure in this regard was Julius Hayes Hess (1876–1955),
pediatrician at the Michael Reese Hospital, the University of Illinois, and the
Cook County Hospital. In 1914, Hess opened a unit for premature infants at the
Sarah Morris Hospital (part of the Michael Reese Hospital), enlarging it several
years later. Hess also fostered the idea of regionalization of health care, with the
premature unit serving the greater community. A prolific author, among other
works Hess wrote Premature and congenitally diseased infants (Hess 1922),
which helped to increase the attention of obstetricians, pediatricians, and others
of the value of these infants and the possibility of saving their lives. In consider-
ing the special problems of these newborns, Hess emphasized the need for proper
hospital-based facilities, and an understanding of the infant’s physiologic needs
vis à vis maintenance of temperature, hydration, and feeding, and avoidance of
infection. In the Preface he wrote.
As part of the great movement toward conserving and developing the individual to his high-
est point of health efficiency, as an important factor in national health, and as an effort
directed toward the source of a considerable morbidity, the care of premature infants and
the conservation of their flickering lives has a prominent place.
(Hess 1922, p. vi)

Hess then acknowledged his “… indebtedness to Dr. Martin Couney … for his
many helpful suggestions in the preparation of the material for this book” (Hess
1922, p. vi). Working with Hess’ group, Couney had a large display of “Incubator
Babies” at Chicago’s 1933–1934 Century of Progress Exhibition, as well as at the
New York World Fair of 1939–1940 (Silverman 1979). In 1941, Hess updated his
volume, with an emphasis on the nursing care of the “preemies” (Hess and
Lundeen 1941), and later summarized his three decades of experience in their care
(Hess 1953). Many of these early developments have been reviewed (Cone 1983;
Dunham 1957).
In Birmingham, England, in 1929 a small maternity home, the Sorrento Maternity
Hospital, was opened for the care of pregnant women with special problems. Two
years later (1931) a young physician with obstetrical experience, Victoria Mary
Crosse (1900–1972), was appointed to establish the “Premature Baby Ward,” a spe-
cial unit to care for those infants born throughout the city. Soon, this included a
motor service to transport such “preemies” from outlying areas of the city. In 1945,
Crosse, by this time Birmingham’s Chief Obstetric Officer and Senior Medical
332 15 Additional Clinical Aspects of Developmental Physiology

Officer, published a volume The premature baby. In this work, she stressed the strict
requirements with attention to detail and unremitting oversight for midwives,
nurses, and physicians working together to minimize morbidity and mortality in this
group of fragile infants (Crosse 1945). In his Foreword to this volume, the genesis
of which he stimulated, Sir Leonard Parsons emphasized Crosse’s nonpareil success
in saving the lives of these infants (Crosse 1945, p. v). The following year in the
introduction to his Blair-Bell memorial lecture delivered to the Royal College of
Obstetricians and Gynaecologists, “Antenatal Paediatrics”.
Sir Leonard concluded with the prophetic words, “The paediatricians of the
future must be concerned with the well-being of the child from the moment of its
conception and sometimes even before that event … When obstetricians, paediatri-
cians and social workers combine together … the future will indeed be radiant with
promise” (Parsons 1946, p. 2 and 15).
One who was influenced greatly by these “Incubator Babies” displays was
Arnold Lucius Gesell (1880–1961), child psychologist and pediatrician at Yale
University. A pioneer in the study of infant development and “the beginnings of the
human mind,” Gesell filmed the “fetal infants” and their reactions at the New York
World’s Fair, obtaining material for his monograph The embryology of behavior
(Gesell 1945), The first five years of life (Gesell 1940), and other works (Radbill
1972). Gesell also obtained considerable information on newborn development
from the “experiment” of “rooming-in.” This was introduced in 1944 at the Yale-
New Haven Hospital by Edith Banfield Jackson (1895–1977), who soon after deliv-
ery placed newborns on the gurney with their mothers for “bonding” (Cooke 1954;
Jackson 1991).
Although criticized by many as overt commercialism and exploitation, there can
be no doubt that with their incubators, hand feeding and care, Couney and others
saved the lives of a small army of premature infants, who otherwise would have
died. Their work drew public and professional attention to the special needs of these
special newborns (Gartner and Gartner 1992). Nonetheless, as Silverman has cau-
tioned, “It would be fatuous to attach deep significance to this odd chapter in medi-
cal history ….” He pointed out that this latter enterprise was, to a great extent, the
result of the activities of a single person, Couney, and had relatively little impact per
se in development of the care of premature and immature infants at either a national
or international level. Tellingly, Silverman compared some aspects of contemporary
NICU theatrics to those of the “incubator baby” sideshows, finding in both a “…
disturbing detachment from reality,” and a “narrowly focused response to [a] …
complex problem.” He closed one of his essays with the comment Plus ça change,
plus c‛est la même chose [the more things change, the more they are the same]
(Silverman 1979, p. 140).
In 1914, August Ritter von Reuss (1879–1954) of the University of Vienna pub-
lished the first comprehensive volume on diseases of newborns (von Reuss 1914;
English translation, 1920). In his 1939 Presidential Address to the American
Pediatric Society, Clifford Grosselle Grulee (1880–1962), of Evanston, IL, reviewed
a number of important problems presented by the newborn infant. In acknowledging
the need for pediatrics to assume a more active role in this regard, he noted, “In
15.1 Preterm Birth and Neonatal Intensive Care 333

previous times the problems of the newborn child have been the province of the
obstetrician, a field in which he has taken comparatively little interest and to which
he had contributed little … As pediatricians we have but scratched the surface”
(Grulee 1939, pp. 2–7). It thus was in the mid-twentieth century that interest in, and
primary responsibility for, care of the newborn infant shifted from the obstetrician to
pediatrician. In 1952, Arthur Hawley Parmelee (1943–2006) of the University of
California Los Angeles, published his Management of the newborn (Parmelee 1952),
one of the first such works in the modern era. With development of neonatal inten-
sive care units, the terms “neonatology” and “neonatologist” had their origin
(Schaffer 1960, p. 1). In contemplating the challenges presented by the rapidly bur-
geoning field of neonatal medicine, Alexander James Schaffer (1902–1981) of
Baltimore, admitted, “We … [are] confronted with the apparently insurmountable
obstacle of our own limitation of knowledge” (Schaffer 1960, p. v).
In the present era, it is perhaps difficult to appreciate the primitive state of care of
the newborn, particularly the premature infant, as late as mid-twentieth century. This
deficit included: little or no appreciation of the healthcare needs of such infants and
a degree of fatalism regarding their outcome, the lack of appropriately trained sub-
specialists in neonatology, a lack of understanding of the pathophysiology of the
many physiologic abnormalities and clinical conditions these infants face, as well as
an absence of equipment and instruments designed specifically for their manage-
ment. Based on relatively rapid advances in understanding pulmonary and other
aspects of physiology, within a brief period NICUs blossomed at several academic
medical centers in the USA, including: Yale, Harvard, Vanderbilt, the University of
California San Francisco, Stanford, the University of Colorado, and others (Cooke
1954). A pioneer in this regard, in the emerging discipline of neonatology and the
development of neonatal training programs was Clement A. Smith (Fig. 15.2a) of
the Boston Lying-in Hospital. For over three decades “Clem” Smith worked in
concert with an outstanding group of Harvard fellow physician-scientists, Duncan
Earl Reid (1905–1973) Chair of Obstetrics, Stewart Hilton Clifford (1900–1997)
Chair of Pediatrics, Claude Alvin Villee, Jr. (1917–2003) in biochemistry, and Kurt
Benirschke and Shirley Driscoll in pathology, to convert the essentially custodial
care of preemies, into the aggressive management that developed “neonatal intensive
care” units (Nelson 2008). This research and patient management involved further
developments for the premature infant of incubators (also called Isolettes), micro
techniques in blood gas analysis, respirator support, transcutaneous oxygen moni-
toring, umbilical vessel catheters, early administration of fluids (Hansen and Smith
1953; Nicolopoulos and Smith 1961), total parental nutrition (Wilmore and Dudrick
1968), and related techniques. All in all, these advances constituted a campaign to
create an extrauterine “womb” in which to keep these newly born fetuses alive.
Of note, a number of these technological advances, such as electrical pressure
transducers, rapid and sensitive recorders, the plethysmograph and pneumotacho-
graph, rapid gas analyzers, cardio-pulmonary monitors, and sophisticated and quan-
titative theories of gas exchange, respiratory mechanics, and cardiovascular
mechanisms, occurred as a consequence of the US space program. Instruments
designed to monitor vital signs of astronauts were adapted for use in medical
334 15 Additional Clinical Aspects of Developmental Physiology

Fig. 15.2 (a) Clement A. Smith (1901–1988), recipient of the first Virginia Apgar Award (1975).
(From left to right) William H. Tooley (1925–1992), Nicholas M. Nelson, Smith, and L. Stanley
James (1925–1994). (b) Mildred Stahlman. (c) Peter M. Dunn. (d) Theodore Lasater Terry
(1899–1946)
15.1 Preterm Birth and Neonatal Intensive Care 335

centers. In the development and inclusion of neonatal intensive care units as

key components of nurseries, Smith and his colleagues played a major role.
In 1946, following the publication of Smith’s Physiology of the newborn infant
(Smith 1945), Sir Joseph Barcroft sent him a photograph and wrote,
My dear Smith … as regards the photograph I am proud to send it to you. Concerning its
effect, you remember that the essence of missionary enterprises such as yours is to expel the
people one by one – in the case of (my) disciples I think it was 70 of them – from the centre
at which they were all over the world. I am sure the effect of the photograph in your
Laboratory will be very similar! These photographs are always rather stilted affairs.
(Avery 1976, p. 857)

Quite obviously Smith rigorously followed Sir Joseph’s counsel, training over
four dozen fellows who became leaders in the discipline and missionaries to the
world. In a highly cited essay, “The Valley of the Shadow of Birth,” Smith used the
metaphor of crossing a deep valley with its turbulent river for childbirth and its
hazards (Smith 1951). The paper is of historical interest, as it also reviews contem-
porary ideas and issues concerning prematurity, respiratory distress syndrome, and
retinopathy of the newborn in the pre-modern era. In 1975, Smith was the first
recipient of the Virginia Apgar Award of the American Academy of Pediatrics
(Nelson 2008) (Fig. 15.2a), and the following year he received the John Howland
Award of the Pediatric Research Society (Avery 1976; Smith 1976).
Louis Gluck has given an account of the development of NICUs and the concept
of “rooming-in” at the Yale-New Haven Hospital (Gluck 1970, 1992). Others have
recorded aspects of the competing ideas regarding construction of a special nursery
for critically ill premature infants (Butterfield 1992; Little 1992; Sinclair et al. 1981;
Sunshine 1992), and Paul Swyer outlined physiological principles on which to base
such intensive care (Swyer 1975). Within a relatively few years, model programs
were developed at many centers for the care of high-risk mothers and their infants
(Sunshine and Quilligan 1974). In the 1960s, although initially respirators were
used only when other modalities of therapy had proven ineffective, by the early
1970s, with their benefits 1.5 kg (~3 lb) infants were surviving almost routinely.
Appropriate therapy of these fragile beings did not develop without some serious
problems in relation to iatrogenic sequelae, as a consequence of the preemies being
delivered and intensive care given to keep them alive at ever earlier and earlier ges-
tational ages (Gellis 1976; Lubchenco 1976; Moore 1976).
A neonatal care center of note, was that developed in the early 1960s by the
pediatrician Mildred Thornton Stahlman (Fig. 15.2b), at the Vanderbilt University
Medical Center, in Nashville, TN. Here, she first used an infant-sized Drinker iron-
lung, tank-type, negative pressure respirator to save a baby with RDS (Cotton
1996). In scientific investigations, Stahlman has emphasized the intimate interrela-
tionship of basic laboratory studies with clinical research in improving patient care
(Stahlman 1984, 1989, 2005). In her 1985 Child Health Day Address at the NICHD,
Stahlman gave an historical perspective of great relevance today. She has written,
The technology needed to study the physiology and biochemistry of both normal and sick
prematures and sick term infants adequately was simply not available. Nothing was the
right size, from respirators to endotracheal tubes, from blood sample size to such simple
336 15 Additional Clinical Aspects of Developmental Physiology

things as cardiac electrodes. The long-honored “hands-off” policy in sick prematures had
not created a demand, either entrepreneurial or commercial. On this backdrop of ignorance
of normal physiology and biochemistry, every new bit of scientific information was excit-
ing, each modifying, in its time, the ability to manage derangements in newborn physiology
which impacted on outcome.
The first so-called NICU’s were all begun by people who were already trained in research
techniques, usually with animal models or in adults. These pioneers, unwilling to accept the
status quo, designed, usually with NIH funding, nursery settings where scientific measure-
ments could be carried out, even on very sick and very premature infants. Their nurseries
were usually backed up by an animal laboratory or a basic biochemical laboratory, where
clinical problems recognized in the nursery could be modeled, or biochemical systems exam-
ined in vitro. These data were taken back to the bedside for clinical trial, and, if successful,
became part of a therapeutic regimen.
(Letter from MTS to LDL, 23 December 2009)

Stahlman then reviewed specific examples of management of asphyxia of the

newborn, the transitional circulation, respiratory distress syndrome, hyperbilirubi-
nemia, and parental alimentation. She concluded.
What can we learn from this recital of past changes in patient care resulting from research?
First: research implies understanding. In every clinical trial, the physician–scientist asks the
parent or the patient to join with him in taking a chance, however small, in testing a new
idea, a new mode of therapy, a new approach to management. This may be better than the
old way of doing things, but may, not only not be better, but actually be worse, not just in
the short term, but also in the long-term effects, apparent only years later. The development
of committees for the protection of human subjects addresses this problem, but in reality,
they only assess informed consent…
Second: advances in science move slowly, in fits and starts, rather than smoothly uphill.
Each piece of new information builds on all the previous ideas and data and trials, provided
by others. We build on the past, and no new information, however trivial it seems at the time
is wasted, if it is true.
Third: The translation of new ideas into clinical care, even those proven superior by
careful trials, is a slow process. We are all creatures of habit, and old ways die hard.
Colleagues have to be convinced, editors have to be convinced, nurses have to be con-
vinced, hospital administrators have to be convinced. It is like the turning of a super-tanker
at sea – the order is given and the rudder is turned long before the wide arc of direction/
change is accomplished. So it is with clinical research.
Fourth: … so many new changes have improved outcome in the NICU, public expecta-
tion has been raised unrealistically for salvage of the unsalvageable, saving of the hopeless.
The public must be kept aware of current limitations and of the continuous need for research
support. We, on the other hand, must never accept these current limitations as permanent.
They are only a temporary resting place, a place for seeing into the future. Tennyson wrote
“yet all experience is an arch wherethrough gleams that untravelled land, whose margin
fades forever and forever as I move.”1 So let it be with us.
Fifth: The role of the physician–scientist in this relationship is crucial, and must be
nurtured and preserved. We are told that he is a disappearing breed, with increasing pres-
sures of hard to get research money, and private practice incentives, both driving him toward
other career goals. It takes many post-graduate years to be a competent neonatologist and at
the same time, a competitive scientist. Recent trends in funding of research training have
made it increasingly difficult to achieve this status. Finally the NIH has recognized this as

1
“Ulysses” a Poem by Alfred Tennyson (1809–1892; 1st Baron Tennyson).
15.1 Preterm Birth and Neonatal Intensive Care 337

a national crisis, and steps are being taken to assure that, if motivation can be restored, train-
ing funds for career physician-scientists will be available.
(Letter from MTS to LDL, 23 December 2009)

Several years earlier, Stahlman had observed.

Throughout the history of newborn intensive care, research has played a major role. Many
early intensive care units were established by research funds, and research has been the
engine that has powered success in all its aspects. The failures have arisen largely from the
acceptance of a new mode of management or a new technology before adequate and
definitive controlled clinical trials have demonstrated its efficacy or potential harm.
Management practices that were designed for or only applicable in specific situations have
crept into generalized use, and, once in the mind-set, removal is virtually impossible.
The importance of basic research in the understanding of fetal growth and development,
the transition from intrauterine to extrauterine life, and the problems facing the premature or
sick newborn cannot be overestimated. Basic research arises from an observation that cannot
be explained by known facts and that challenges the observer to ask why, not how. This
generates a cascade of hypotheses to be tested, each based on the addition of information
derived from answering the prior question. The satisfactory answering of a question may
depend on the level of the development of a given technology at a particular point in time,
but technology has never posed a question or generated an original idea. The few people who
stubbornly ask why are our national treasures. The translation of their basic principles into
medical practice is the last and least original step in the production of better medical man-
agement that takes full advantage of the most advanced technology. The relative place of this
final step in the scientific advancement of medical knowledge should never be forgotten.
(Stahlman 1989, p. 1791)

As Stahlman has reflected, “In the long run it is the intellect, the integrity, and the
conscience of the physician–scientist that must fulfill the tenet [of Hippocrates
(460–375 BCE)] primum non nocere [first do no harm]” (Stahlman 1992, p. 20). As
with the institution of Intensive Care Units for adults, the concept of NICUs rapidly
spread throughout the developed world. (For instance, for the UK see Christie and
Tansey 2001.)
Another champion for the vital necessity of neonatal intensive care for the pre-
mature infant, was William Silverman (Silverman 1959, 1970). In a 1989 review of
“Neonatal pediatrics at the century mark,” Silverman divided neonatal intensive
care into the first 70 years, a “pastoral era,” and the last 30 years, as a more intense
“mechanistic era” extending to the present. Following a review of the vicissitudes
during these years, he cautioned.
After basic mechanisms concerning isolated phenomena have been worked out and rigor-
ously battle-tested in preclinical studies, there is an understandable temptation to translate
the hard-won information into practical action as soon as possible. But the lesson of history
in neonatal medicine is very clear: at every turn, in the search for effective treatments, there
are traps to snare the impatient innovator. It has been said that nature is a tyrant queen: make
a mistake and she cuts off your head.
In medicine we are always tempted by the optimistic vision of a dramatic therapeutic
success. Our daily experience with misery and death makes us desperate to help, but, para-
doxically, we need to be preoccupied with the negative aspects of innovation. The reason
for this guarded attitude goes back to the fact that our observations about complex events in
the natural world are never complete. There are, in fact, no criteria that would even allow us
to judge completeness. Nonetheless, doctors, like engineers (and unlike scientists), are
338 15 Additional Clinical Aspects of Developmental Physiology

obliged to act on the basis of incomplete information about material phenomena. Action in
the applied sciences is always an informed compromise. Compared with the small pond of
knowledge in medicine, our ignorance is Atlantic.
(Silverman 1989, p. 165)

A decade later, Nicholas M. Nelson categorized the first half-century (1900–

1950) as an “Era of Compassionate Observation” during which physicians practiced
minimal intervention (Nelson 2000). This was followed by an “Era of Passionate
Intervention” (ca. 1950–1980) during which a “… cornucopia of technology”
helped to erect the edifice of contemporary neonatology. This, in turn, has been suc-
ceeded by the “Era of Reflective Consolidation” (ca. 1980–2000) that presently
exists (Nelson 2000, pp. 731–733). As Nelson emphasized, the advances that helped
to create the newest era had their roots in sociology, technology, biology, and
physiology.
As noted, in conjunction with conceptual advances in understanding physiology
per se, of vital importance were those of medical technology. For the management
of respiratory problems in premature and other newborn infants was the 1970 intro-
duction of the BabyBird respirator. Forrest M. Bird created and marketed the first
low cost, medical ventilator on a large scale, the Bird Universal Medical Respirator
(1955; Bird Mark 7), which contributed greatly to management of individuals with
respiratory failure and related conditions. In 1992, the VIP Bird® Infant Pediatric
System was introduced. Recipient of many honors, in 2008 Bird was awarded the
US Presidential Citizens Medal. As noted earlier, other vital technological advances
to lessen morbidity and mortality in the prematurely born infant, included micro
analysis for blood gases, electrolytes, bilirubin, and so forth, and specially designed
equipment such as plastic small-bore endotracheal tubes, umbilical vessel catheters,
electronic monitoring of newborn vital signs and oxygenation status, transcutane-
ous oxygen monitor, small infusion pumps, equipment to provide parental nutrition,
and other advanced devices. In conjunction with these developments, advances in
care of the newborn includes the maintenance of thermal stability and nutrition,
antibiotics to combat infection, and other measures (Dunn 2007; Philip 2005),
including institution of the “Usher regime” of intravenous bicarbonate infusion to
correct metabolic acidosis, with glucose and insulin (Usher 1959, 1963).
In the USA and other developed countries, the 1970s saw an additional important
factor in the success of NICUs in saving the lives of critically ill infants and decreas-
ing their morbidity. This was the appreciation of the necessity of regionalization of
healthcare, with such facilities being located in tertiary medical centers (Butterfield
1992; Lewis 1977; Lucey 1973; McCormick et al. 1985). A Committee on Perinatal
Health of the National Foundation—March of Dimes, and its report “Toward
Improving the Outcome of Pregnancy” also played a role in this regard (Committee
on Perinatal Health 1976). In view of the “staggering cost” and “scarcity of person-
nel” for comprehensive care to mothers and infants at high-risk (Committee on
Perinatal Health 1976), the guidelines for regionalization, avoiding duplication of
effort, became a standard for which to strive. This concept was stimulated, in part,
by a demonstration in Quebec, Canada (Carrier et al. 1972; Usher 1970). Here,
establishment of a Province-wide program that mandated transfer of high-risk new-
borns to regional centers, quickly reduced morbidity and mortality. Soon, this
15.1 Preterm Birth and Neonatal Intensive Care 339

concept was inaugurated throughout Canada. Importantly, Usher (Fig. 15.1d) and
others recognized that more was needed than simply providing intensive care for
the newborns per se. To further improve survival, they advocated establishment of
“Perinatal Centers,” in which high-risk mothers would deliver their infants, which
then could receive optimal professional intensive care (Segal 1972; Swyer 1970;
Usher 1970). An additional argument for regionalization of care was, that it was
only in such tertiary centers with a number of infants, that randomized controlled
clinical trials could establish the therapeutic value of various modalities of preven-
tion and therapy (Lucey 1973; Nesbitt 1974), e.g., “evidence-based” medicine.
Jerold Frances Lucey of the University of Vermont, and editor of Pediatrics, with
colleagues also advanced the concept of calculating birth weight to gestational age
ratios to compare statistics from different tertiary care centers (Philip et al. 1981).
In addition to major advances in technology and therapy, attention to sociological
and psychological considerations have been important in care of these fragile and
usually premature human beings at the beginning of life. In her Newborn medicine
and society …, Murdina MacFarquhar Desmond of Baylor College of Medicine,
Houston, TX, has chronicled the history of care of the newborn infant with the evo-
lution of neonatal intensive care in its social context (Desmond 1998).
Peter MacNaughton Dunn (Fig. 15.2c) has presented several accounts of the devel-
opment of perinatal medicine and neonatal intensive care in the UK (Dunn 1978, 1983,
1998, 2003, 2007). In addition, he has written several dozen essays that feature the
“great physicians” in “Perinatal lessons from the past,” and which have appeared in the
Archives of Disease in Childhood. Of special relevance, Dunn has pointed out the seri-
ous challenges that faced those who, in the early years (1950s and 1960s), devoted
themselves to newborn care. These included: the relative neglect of intensive perinatal
care by pediatricians and obstetricians, the lack on the part of many in authority of the
importance of the problem, inadequate staff, the absence of training programs in neo-
natology, the lack of appropriate equipment, little experience with the clinical problems
with which one dealt, and the multiple errors made in dealing with these complicated
issues (Dunn 1998, 2007). Dunn also has documented the struggles and development
during these years of Special Care Baby Units, as appreciation for the need of special-
ized neonatal care followed the 1948 enactment of the National Health Service. Dunn
has documented from that time forward, many aspects of the advances in newborn
care, particularly those that are premature. About this time, an editorial in The Lancet,
while in part addressing the issue of retrolental fibroplasia, noted.
Most of our nurseries for the newborn are still without the means of monitoring environmen-
tal and arterial oxygen, even though the necessary equipment has been available for at least
a decade; and resident paediatric staffing of all but the largest maternity units is virtually
non-existent. The facts are sombre. Each year in Britain more than 17,000 babies die in the
perinatal period, a number equivalent to deaths from all causes over the next 28 years of life.
Almost as many deaths take place during the first week of life as during the whole of the
remainder of childhood. Analysis suggests that this mortality might be reduced by at least a
third and possibly by half if modern knowledge and resources in perinatal care were made
generally available throughout the country. … Surely the time has come to recognise on both
humane and economic grounds that the cost of continued perinatal neglect is far too great.
(Anonymous 1974, pp. 437–438)
340 15 Additional Clinical Aspects of Developmental Physiology

As observed earlier, advances in neonatal care included continuous positive

airway pressure to improve ventilation, attention to thermal stability, monitoring
acid–base status, preventing retinopathy from excessive O2, hypoglycemia, the use
of parental nutrition, and other modalities. Importantly, Dunn also has offered a
number of personal recollections of his role in advancing the frontiers including
helping to found and foster the British Association of Perinatal Medicine, its contri-
butions to life, and incorporation into a multidisciplinary body with profound influ-
ence for good (Dunn 2003, 2007). In addition, he has recorded efforts of the joint
British Paediatric Association—Royal College of Obstetricians and Gynaecologists
Liaison Committee under his chairmanship (1978), to prepare a comprehensive
series of recommendations to improve care during the perinatal period (Dunn 1978,
2007). During the 1970s these special care baby units evolved into full-fledged
NICUs and have played a vital role in increasing fetal and neonatal survival and
well-being (Dunn 2007).
A Wellcome Trust “Witness to twentieth century medicine” conference, chaired
by Robert (later Sir Robert) Boyd (Fig. 14.2c) of the University of Manchester also
has reviewed many aspects of development of neonatal intensive care in the UK,
and their dependence upon, and close association with, advances in fetal and neona-
tal physiology (Christie and Tansey 2001). As noted, the 1974 Lancet editorial “The
price of perinatal neglect,” drew attention to the extreme need for properly trained
neonatologists and appropriate care of the newborn. After mentioning many of the
iatrogenic-induced diseases including retrolental fibroplasia with blindness (exces-
sive oxygen), hypothermia, hypoglycemia, kernicterus (excessive vitamin K), “gray
baby” syndrome (chloramphenicol), and others, the editorial writer emphasized the
fact that in Britain, although first-day mortality among low-birthweight newborns
decreased in the previous decade, an excessive number continue to die. “Analysis
suggests that this mortality might be reduced by at least a third and possibly by half
if modern knowledge and resources in perinatal care were made generally available
throughout the country. Moreover, mortality is only a fraction of total perinatal mor-
bidity” (Anonymous 1974, p. 437).
Several reviews have explored various aspects of the history and immense con-
tributions of neonatology (Cone 1983, 1985; Yaffe 1992), including the evolution of
neonatal intensive care in terms of the “Hands Off” years prior to 1950 (Robertson
2003a; Silverman 1989), the “Heroic” years from 1950 to 1970 (Robertson 2003b),
and the “Experienced” years, 1970–2000 (Robertson 2003c).

15.2 Retinopathy of Prematurity

As noted, management of the premature infant has presented numerous challenges.

A report of blood O2 requirements in early life documented the relative lack of data
and disagreement regarding the available data on the optimal arterial blood O2 levels
for the newborn. As it became appreciated that the skin color of premature neonates
was an unreliable indicator of their state of oxygenation, a related question
15.2 Retinopathy of Prematurity 341

concerned the extent to which these infants suffered from “subcyanotic anoxia”
(Smith and Kaplan 1942). In the misguided belief that following birth the infant
should quickly achieve arterial blood gas values similar to those of the adult, oxy-
gen became widely over-used. Placing the situation in perspective, William
Silverman observed that O2 therapy had become an “albatross” for the neonatologist
(Silverman 2004). Also as Silverman noted, one of the factors leading to hyperoxy-
genation was the fact that in the early years, incubators were a kind of pressure
cooker, with tight fitting gaskets and novel O2 intake float valves, almost insuring
maintenance of elevated O2 levels (Silverman 2004).
A bittersweet sequelae in the treatment of infants with respiratory disease syn-
drome with elevated oxygen levels (for many of whose lives were saved), was the
development of what originally was referred to as retrolental fibroplasia (RLF) with
blindness. The “first epidemic,” of what later would be called retinopathy of prema-
turiy (ROP), was reported by the Boston ophthalmologist-pathologist, Theodore
Lasater Terry (1899–1946) (Fig. 15.2d), who termed it amblyopia ex anopsia [dull
vision that results from disuse] (Terry 1942). Terry believed this to be a conse-
quence of persistence of the hyaloid artery with fibroblastic overgrowth of persis-
tent tunica vasculosa lentis [vascular coat of the lens] (Terry 1943). In his 1944
report of 160 cases from Boston, Chicago and other cities, Terry introduced the term
retrolental fibroplasia, pointing out that this condition develops in about 10 % of
premature infants weighing less than 3 lb (Chandler 1947; Terry 1944, 1945).
Numerous reports soon appeared from other centers (Hepner et al. 1950; Hipsley
1952; Kinsey 1950, 1951; Kinsey and Zacharias 1949). At the Johns Hopkins
Hospital, Baltimore, ophthalmologist husband and wife team William Councilman
Owens (1917–2006) and Ella Uhler Owens (1914–1999), demonstrated that RLF
developed postnatality in 12 % of infants weighing less than 1,360 g (3 lbs), and that
it did not involve the hyaloid vascular system (Owens and Owens 1949a). Although
they believed the condition to be a consequence of imbalance of Vitamins A and E,
and that it could be prevented by treatment with the antioxidant d-1 alpha tocoph-
erol acetate (a form of vitamin E) commencing in the first week following birth
(Owens and Owens 1949b), this proved not to be the case. In a subsequent report,
Owens and Owens placed the RLF prevalence higher, at 15 % in infants who
weighed less than 1,360 g, and recorded that in these infants the first ophthalmo-
logic changes occur at 4 weeks of age, with the retrolental membrane fully formed
by 4 months of life (Owens and Owens 1950). By mid-century RLF had become the
most common cause of blindness in children (Tasman et al. 2006).
The role of oxygen in the genesis of this disorder first was suggested by a com-
parison of the incidence of RLF in the USA where O2 therapy was used freely, with
that in the UK where it was used more sparingly. In conjunction with hyperoxia,
Kate Isabel Campbell (1899–1986) of Melbourne associated RLF with the develop-
ment of edema in loose connective tissue in the premature infants. In a survey of
three Melbourne nurseries, she reported that of 123 infants in a “High-oxygen”
group, 23 developed RLF (18.7 %). In contrast, among infants in the “moderate-
oxygen therapy” group, (for which the families were charged for each tank of oxy-
gen used), only 4 of 58 (6.9 %) developed this disorder. Campbell concluded that in
342 15 Additional Clinical Aspects of Developmental Physiology

cases of cyanosis, O2 only should be given in amounts to “… keep the infant’s

colour satisfactory” (Campbell 1951, p. 49). In 1966, the University of Melbourne
conferred upon Campbell the degree Doctor of Laws honoris causa [with public
esteem and honor].
Following a 1947 visit to the USA, during which she learned of the increasing
prevalence of RLF, the Birmingham neonatologist Victoria Mary Crosse reported
on the low prevalence of this disorder in her experience (14 cases in over 6,000
deliveries of preemies from 1945 to 1950), and that 12 of the 14 cases had been
given continuous O2 for periods varying from 2 to 5 weeks (Crosse 1951). About
this same time, from experimental studies in newborn kittens exposed to 60–70 %
O2, the first ophthalmic pathologist in the UK, Norman Henry Ashton (1913–2000)
and colleagues of the University of London, demonstrated RLF to be a consequence
of hyperoxia-induced vasoconstriction (vaso-obliteration), followed upon return to
atmospheric air by “a re-opening of the vessels.” Many vessels remained perma-
nently obstructed by collapse or blood clot, however, so that the normal architecture
was not restored. “The reformed network was grossly abnormal, haemorrhages
occurred, retinal re-vascularization recommenced from the disc, blood vessels grew
into the vitreous, and retinal detachment developed… These phenomena are
regarded as significant in the genesis of retrolental fibroplasia in man” (Ashton et al.
1953, p. 520). Over the next decade, Ashton would explore several aspects of the
role of oxygen in the development of the retinal vasculature (Ashton 1966, 1970a, b;
Ashton and Blach 1961; Ashton and Pedler 1962). As head of the Institute of
Ophthalmology, Ashton became a world authority in many aspects of this field. A
recipient of many honors, he was a Fellow of the Royal Society, and in 1976 was
made Commander of the Order of the British Empire (Luthert and Langley 2005).
Also at this time, in rats and mice (but not opossums) subjected to 60–80 % oxy-
gen for several days, Arnall Patz (1920–2010), of the District of Columbia General
Hospital, Washington, DC, and subsequently of the Wilmer Eye Institute, The Johns
Hopkins University, Baltimore, also demonstrated the role of oxygen as being a
causative factor in the genesis of RLF (Patz et al. 1952, 1953; Tasman et al. 2006).
Later, he defined this association further (Patz 1955; Patz and Eastham 1957a, b).
For his many contributions to life, and to understanding the pathogenesis of reti-
nopathy of the newborn, in 2004 Patz was awarded the Presidential Medal of
Freedom.
Another early report that demonstrated the virtues of limiting ambient O2 levels
was that of Joseph Dancis and colleagues at the New York University-Bellevue
Medical Center. Reporting on 148 surviving infants of birthweights less than 2,000 g
over a two and one-half year period, these workers demonstrated that not one case
of cicatricial retrolental fibroplasia was observed among those infants who had
received of less than 40 % O2, administered for brief periods as possible and only
when clinically required (Guy et al. 1956).
Because so much controversy surrounded the early reports of RLF, under the
aegis of the National Institutes of Neurologic Disease and Blindness, 18 major cen-
ters in the eastern USA agreed to a cooperative prospective randomized control
clinical trial which involved about 750 premature infants (grouped by weight:
15.2 Retinopathy of Prematurity 343

1,000 g or less, 1,001–1,250, and 1,251–1,500 g). The study compared the use of
“routine” (high) (FIO2 > 50) oxygen for 28 days with the “curtailed” (FIO2 < 50 %)
oxygen (the latter given only for cyanosis or respiratory difficulty). In these two
oxygenation groups the observed RLF incidence were 22.6 % and 6.6 % (p < 0.01),
respectively (Kinsey 1956; Kinsey and Hemphill 1955). Thus, the role of hyperoxia
was confirmed in the human newborn, and O2 use was recommended to be limited
to less than 40 % for as short a period of time as possible. Nonetheless, this study
left many questions unanswered, including the genesis of retinopathy of prematu-
rity in this infant cohort. As Silverman has critiqued, unfortunately debate ended
and the mantra “under 40 % is safe” was accepted as Gospel; and if an infant devel-
oped RLF it was held as proof that the 40 % FIO2 limit had been exceeded (Silverman
2004, p. 395). Two decades later, in an attempt to define further the level of arterial
O2 tension and exposure duration responsible for development of retrolental fibro-
plasia, under the aegis of the National Society for the Prevention of Blindness, many
of the same investigators conducted a further five university center study of 589
low-birth-weight infants (Kinsey et al. 1977). Because of failure to maintain rigor-
ous methods, this report continued the confusion. Also, in a letter to the editor, two
“disenchanted investigators” soundly criticized the study, not only pointing out
methodologic deficiencies, but stressing the need for a large properly collaborative
controlled trial to address the issues involved (Les Chermignonards Désenchantés
1977). In reaction to this anonymous critique, the original authors wrote a blistering
response (Kinsey et al. 1978). Aside from demonstrating again an association of
RLF with O2 levels among the low birth weight (<1,200 g) infants, the study empha-
sized that intermittent and infrequent blood gas measurements may not reflect true
arterial PO2 values (Kinsey et al. 1977; see Lucey 1977). In commenting on this
“second epidemic” of RLF (Phelps 1981), Jerold Lucey cautioned “… no criteria
exist which guarantee the safe use of oxygen in very low birth weight infants … It
is time to admit our ignorance and to begin new studies which might help us in
finally preventing this disease” (Lucey 1982, p. 497).
As a “parable for modern man,” Silverman documented aspects of this tragedy
including the design of clinical studies such as those quoted. Silverman, and others,
emphasized the requirement for controlled clinical trials to establish optimal thera-
pies for medical conditions about which little is known (Silverman 1980b, 1987). A
report of the “Early treatment for retinopathy of prematurity cooperative group,” in
which almost 7,000 infants from 26 centers in the USA were screened, concluded
that among those preemies weighing <1,251 g or less, the incidence of ROP, its time
of onset, rate of progression, and timing of prethreshold disease have changed little
during the previous two decades (Good et al. 2005). A subsequent retrospective
study, based on the National Inpatient Sample maintained by the Ageing for
Healthcare Research and Quality of 34 million live births from 1997 through 2005,
reported on ROP incidence of 15.6 % in premature infants (many of which had
associated intraventricular hemorrhage) whose length of hospital stay was more
than 28 days (Lad et al. 2009). The paradox remains in treating critically ill new-
borns that, although lower levels of O2 reduce the risk of retrolental fibroplasia,
levels that are too low increased deaths from respiratory distress (Stenson 2011),
344 15 Additional Clinical Aspects of Developmental Physiology

and some believe that it may increase the chance of survival with cerebral palsy or
other neurologic disorder. Several reports consider the dilemma of optimal oxygen-
ation, while avoiding the hazard of hyperoxia with superoxide generation with con-
sequent damage (Fabian et al. 2008; Saugstad 2008; Saugstad and Aune 2011;
Saugstad et al. 2011). In … A guided step into the unknown Silverman reviewed
many aspects of clinical trials and human experimentation (Silverman 1985). As
observed by others, during the past half century or more, “oxygen must have been
given to more infants than any other medical product … yet we still know very little
about how much … [they] actually need, or how much it is wise to give. … Fifty
years of observational study have gotten us nowhere” (Tin 2002, p. 615; see also Tin
et al. 2001). More recently, details of the pathophysiologic mechanisms of early
vascular disease have been suggested, with a two-phase hypothesis distinguishing
between physiological retinal vascular development and vasoproliferation, as well
as aspects of management (Hartnett and Penn 2012), with target ranges for arterial
[HbO2], in preterm infants (Tarnow-Mordi et al. 2010).

15.3 Transcutaneous O2 Measurements

As noted, the moments of transition from fetus to newborn poses an extraordinary

challenge for the neonate, especially for one that is premature. Indeed, a number
of such infants require vigorous resuscitation to achieve postnatal stability. While
in the delivery room and thereafter, positive pressure ventilation and oxygenation
are the most relevant interventions. Nonetheless, a challenge for neonatologists is
that of the infant O2 needs during resuscitation. While hyperoxia is associated
with the generation of oxidative stress and reactive oxygen species, hypoxia also
can be associated with these as well as a number of serious short and long-term
sequelae. As may be appreciated from the above account of the role of oxygen in
retinopathy of prematurity, of critical importance is the necessity of monitoring
O2 levels in arterial blood and tissues. Supplemental O2 is of course vital to neo-
natal resuscitation, and many aspects of intensive care. A two edged sword, in the
premature infant O2 excess with toxicity is associated with severe disorders in
addition to ROP including bronchopulmonary dysplasia (Merritt et al. 2009), neu-
rologic disabilities (Marlow et al. 2005; Wolke et al. 2008), and many other condi-
tions (Sola 2008). To complicate the picture, controversy continues to surround
several aspects of the issue of monitoring O2 levels (Klein et al. 2010; Merritt and
Mazela 2010).
Following the invention of O2 and CO2 electrodes, and their fabrication for
application in anesthesia and intensive care medicine, these were adapted to mea-
sure continuously and in a non-invasive manner, blood gas values through the
skin. Originally developed to measure the metabolic rate of skin, and based on
earlier studies by others, in the late 1960s Dietrich Werner Lübbers (1917–2005)
of the Department of Applied Physiology, University of Marburg, commenced
15.3 Transcutaneous O2 Measurements 345

developing methods to measure capillary [HbO2] levels (Lübbers 1966, 1981,

1987) and transcutaneous Po2 and Pco2 levels (tcPo2 and tcPco2, respectively;
Lübbers et al. 1973, 1979). Lübbers has reviewed the theory and development of
these methods (Lübbers 1979, 1981, 1987). Soon, he was joined by the husband
and wife team Albert and Renate Huch, who, stimulated by the intermittent fetal
scalp blood sampling studies of Erich Saling of Berlin (see below), sought to
develop a method to measure continuously O2 levels in the presenting fetal scalp
during late labor and delivery. They also sought to correlate these measurements
with electronic FHR rates (Huch and Huch 1979, 1985; Huch et al. 1981; Lübbers
et al. 1973). Because of its complexity, a number of problems plagued this trans-
cutaneous methodology including: maintenance of electrode contact during the
course of labor, calibration of the electrode, differing reflection coefficient of skin
versus that of hemoglobin, the nonhomogeneous distribution of capillaries and
hemoglobin in the skin area studied, and the need to heat the skin to 43–45 °C, or
produce hyperemia by other means to arterialize the capillary bed. In a collabora-
tion with the pediatrician Gösta Rooth (1918–2008) at the University of Lund
(and later at the University of Uppsala), Sweden, using a Po2 electrode on an adult
they obtained transcutaneous Po2 measurements that mirrored closely (with a
delay of ~30 s) that of arterial blood (Huch et al. 1972, 1973a). Subsequent studies
in newborn infants confirmed these findings, and demonstrated that while this
methodology was impractical for the fetus during the course of labor and delivery,
it had great potential for the newborn (Huch and Huch 1979, 1985; Huch et al.
1973b, 1981).
Also in an effort to monitor continuously arterial blood gas values by transcuta-
neous microelectrodes, anesthesiologist and authority in blood gas analysis John
Wendell Severinghaus of the Cardiovascular Research Institute, University of
California San Francisco and colleagues, worked to develop these for both tcPO2
(Severinghaus et al. 1978a) and tcPco2 (Severinghaus 1977; Severinghaus et al.
1979). In several reports he described their fabrication, calibration, selection of skin
site, preheating, estimation of skin diffusion resistance, and computation of arterial
Po2 and Pco2 from the tcPo2 and tcPco2 values (Severinghaus 1982, 1983;
Severinghaus et al. 1978b). In newborn infants, his group established the surpris-
ingly close relationship of tcPo2 to arterial Po2 (Peabody et al. 1978), and showed
that the heating power used by these electrodes usefully monitors mean arterial
pressure in the compromised newborn (Peabody et al. 1979). A 1978 international
symposium, held in Marburg, West Germany, under the aegis of the National
Foundation March of Dimes, presented almost 90 reports reviewing various aspects
of the techniques and results of transcutaneous O2 and CO2 monitoring in obstetrics
and pediatrics (Huch et al. 1979).
As technology has improved and the cost of equipment decreased, over the
past several decades, transcutaneous measurements of arterial PO2 and PCO2 has
become routine. In addition, pulse oximetric estimation of arterial oxyhemoglo-
bin saturation (reported as SpO2), developed in the 1980s and 1990s, has signifi-
cantly reduced the need for transcutaneous measurements. Nonetheless, despite
346 15 Additional Clinical Aspects of Developmental Physiology

several clinical trials the dilemma of maintaining optimal oxygenation while

avoiding the Scylla of hyperoxia and Charybdis of hypoxia, remains a challenge
in neonatal care (Rosychuk et al. 2012; Saugstad and Aune 2011; Saugstad et al.
2011; Vento 2011).

15.4 Thermoregulation

Because of several factors such as its relatively large skin surface area to body mass,
its limited ability to generate heat through muscular contraction (shivering thermo-
genesis), and its relatively poor thermal insulation from the environment, the new-
born infant is vulnerable to body heat loss and hypothermia. Thus, following birth,
temperature of the mammalian newborn falls. Beginning in the late-nineteenth and
early-twentieth century, the importance of regulation of newborn temperature came
to be appreciated. Understanding the physical/chemical processes by which an
infant, particularly the premature, regulates is body temperature as a homeotherm
(or endotherm, e.g., maintains constant body temperature), as opposed to a poikilo-
therm (or ectotherm, e.g., having body temperature equal that of ambient tempera-
ture), was aided by the development of incubators. A 1930s study from Boston had
suggested that the premature infant could not maintain body temperature equal to
that in utero because of incomplete neural development. It also suggested that sub-
normal temperatures were a “characteristic” of prematuriy, and that attempts to
maintain its body temperature at 37 °C (98.6 °F) may be detrimental to optimal
growth, even leading to death (Blackfan and Yaglou 1933). Not until the mid-1950s,
however, did a series of randomized, controlled, clinical trials by William Silverman,
and colleagues at Columbia University, establish the vital importance of thermal
stability for survival of preterm infants (Silverman 1959; Silverman et al. 1958). In
turn, this work was based, in part, on that of Richard Lawrence Day (1905–1989),
originally at Columbia University and later at Cornell (Day et al. 1943), and others
(Mann and Elliott 1957; Mordhorst 1932), demonstrating that premature infants,
most of whom were 1 week of age or older, increased their metabolic rate on expo-
sure to cold air. These studies also demonstrated that newborn survival was signifi-
cantly greater in an atmosphere of 80–90 % relative humidity, as compared to that
at 30–60 % (incubator air temperature was 84 °F, 28.3 °C in both groups). Of note,
core body temperature of infants maintained at the higher value of relative humidity
was significantly greater; leading the authors to postulate a “normothermic hypoth-
esis,” that survival was optimized in an environment that maintained their tempera-
ture at the elevated temperature (Silverman and Blanc 1957). Silverman also
reported lower mortality at a higher ambient temperature (89 °F, 31.7 °C; Silverman
1959). Silverman later appreciated that the lower mortality at high humidity was
due to less evaporative heat loss, and that in very early preemies, small increases in
body temperature contributed greatly to survival (Silverman 1994). Following the
early studies, factors regulating infant heat production versus heat loss were eluci-
dated (Sinclair 1970), and it came to be appreciated that, to maintain normal
15.5 Some Aspects of the Development of Maternal–Fetal Medicine 347

physiologic functions, infants required a “neutral thermal environment” or “thermal

neutral zone” dependent upon gestational age and birthweight. Shortly thereafter,
incubators with temperature servo-control were introduced.
In regard to heat production in the developing organism, studies at Oxford’s
Radcliffe Infirmary, demonstrated in newborn kittens and rabbits a striking rise in
O2 consumption following infusion of norepinephrine, a phenomenon that was
essentially absent by 20 days of age (Scopes and Tizard 1963). Soon, based by on
the large increase in heat production by the newborn rabbit upon exposure to cold,
David Hull (later Sir David) and his Oxford colleagues, identified brown adipose
tissue as a specialized heat-producing organ for the newborn infant (Aherne and
Hull 1964, 1966; Dawkins and Hull 1964; Hull 1966). Brown adipose tissue in the
newborn, much of it located around arteries in the neck, in the mediastinum, and in
the abdominal cavity, had been recognized earlier, as being similar to intrascapular
and auxiliary fat, as well as that of the “hibernating gland” located in the mediasti-
num and neck of hibernating mammals (Carlier and Evans 1903; Rasmussen 1923).
This tissue also was known to have a rich blood supply, a wealth of mitochondria,
and to be of vital importance in the regulation of body temperature (Brück 1961;
Johansson 1959). Rich in mitochondria, by metabolism of free fatty acids within the
cells (Dawkins and Hull 1964), brown adipose tissue serves as a site of non-shivering
thermogenesis (Aherne and Hull 1966; Dawkins and Scopes 1965; Hull 1966).
Brown adipose tissue content is greatest in the premature infant, decreasing with
age (Aherne and Hull 1966). Brown adipose tissue now is recognized to be a pri-
mary site of energy expenditure through sympathetic-initiated thermogenesis,
mediated, in part, by epigenetic-mediated conversion of circulating thyroxine (T4)
to the more active triiodothyronine (T3) with upregulation of mitochondrial uncou-
pling protein (Cannon and Nedergaard 2004). This allows brown fat mitochondria
to produce heat without producing energy in the form of ATP. For newborns of dif-
fering gestational age and size, a range of temperatures that constitute the “neutral
thermal environment,” has been found to minimize energy expenditure (Hey 1975).
Arlin Brice Blood and Gordon Gilbert Power (Fig. 15.3a) of Loma Linda University
have reviewed in extenso thermoregulation in the fetus and newborn infant, its regu-
lation by O2 availability, hormones, and other factors (Power and Blood 2011).

15.5 Some Aspects of the Development of Maternal–Fetal

Medicine

From a clinical standpoint, an obvious necessity during pregnancy is the assurance of

fetal well-being culminating in the delivery of a healthy infant. Thus, periodic assess-
ment of the developing fetus is key to reducing the risk of antepartum fetal death.
During the first decade of the twentieth century, the field of maternal–fetal medicine
commenced initially as a social movement of maternal and child health. A veritable
public crusade flowered for the improved care of pregnant women and their children,
an advance that had its roots in concern for the astonishingly high death rates during
348 15 Additional Clinical Aspects of Developmental Physiology

Fig. 15.3 (a) Arlin B. Blood, Christian J. Hunter, Shannon L. Bragg, and Gordon G. Power.
(b) John W. Ballantyne (1861–1923). (c) John Whitridge Williams (1866–1931). (d) Erich Saling.
(e) Edith Potter (1901–1993)
15.5 Some Aspects of the Development of Maternal–Fetal Medicine 349

the first few years of life. Pediatricians, obstetricians, nurses, public health workers,
and women’s groups strove to establish well-baby clinics, assure clean milk supplies,
and eliminate the waves of epidemic infections that accounted for a huge loss of life.
Soon it was realized, however, that without properly managed pregnancy, the benefits
of pure milk were limited. Concurrently the works of John William Ballantyne
(1861–1923) (Fig. 15.3b) at the University of Edinburgh (Ballantyne 1902–1904)
and John Whitridge Williams (1866–1931) (Fig. 15.3c) at the Johns Hopkins
University (Williams 1903), helped to focus attention on several issues, including the
enormous numbers of mothers who died of pregnancy-related disorders. Another
focus of attention was on the diseases of young children that had their origin during
fetal life, and the realization that to a certain extent, the fetus could be treated by cor-
recting the underlying pathologic condition in the pregnant mother. These ideas con-
tributed to the origins of prenatal care (Longo 1988).
Early in the century, the Association for the Study and Prevention of Infant
Mortality had been organized (1909) (Williams 1910), which promoted studies in
maternal and child care. In 1912, as a consequence of a White House Conference on
Child Welfare Standards, the Children’s Bureau of the Department of Labor was
established. Its mission was for the purpose of “… investigating and reporting on all
matters pertaining to the welfare of children and child life among all classes of
people” (Longo 1988, p. 7). Under the leadership of Julia Clifford Lathrop (1858–
1932), the Bureau conducted numerous early studies relating to maternal and child
health. At this time in the USA, leaders in promoting more scientific obstetrics and
pediatrics included the obstetricians Williams and Joseph B. DeLee, pediatricians
such as Abraham Jacobi (1830–1919) (Jacobi 1887), and Luther Emmett Holt
(1855–1924) (Holt 1894). In the UK, these included obstetricians such as John
Martin Munro Kerr (1868–1960), William Blair-Bell (1871–1936), Sir John Harold
Peel (1904–2005), and pediatricians such as Sir Leonard Parsons (Parsons and
Barling 1933).
Until mid-twentieth century, the only way of interrogating the developing fetus
in utero was by assessing its movements or stethoscopic auscultation of the heart.
As noted in an editorial of the time, entitled “Foetal medicine—who is to
practise it?”,
Up to now the formidable inaccessibility of the human foetus has meant that foetal medi-
cine (apart perhaps from foetal electrocardiography) has virtually not existed. In an age
when Man has been able to measure most things from an atom to a galaxy, it is thus para-
doxical that to measure his own size during the most critical and precarious period of his
life, he still has to depend upon the extreme fallibility of the palpating hand.
(Anonymous 1966, p. 453)

After pointing out that to this time, because of the obstetrician’s prime interest in
the pregnant mother, and that of the pediatrician in the newborn, “… the foetus has
been nobody’s baby,” the editor noted further,
With the advent of the techniques of amnioscopy and foetal blood sampling … and of
amniocentesis and foetal transfusion … we witness the end of the long period of foetal inac-
cessibility and, we hopefully believe, the start of the science of foetal medicine.
(Anonymous 1966, p. 453)
350 15 Additional Clinical Aspects of Developmental Physiology

The editorial concluded with the inquiry, “… is a new kind of doctor needed, at
least at the academic level, who, by combining the interests and skills of both the
obstetrician and the paediatrician, can act as the foetus’s doctor?” (Anonymous
1966, p. 453).
As noted, two visionaries in the development of what today we call maternal–
fetal medicine were John William Ballantyne of Edinburgh and John Whitridge
Williams of Johns Hopkins University. Ballantyne introduced the idea of a “Pro-
maternity Hospital” to provide inpatient antenatal care with preventive medicine for
obstetrical patients (Ballantyne 1901, 1923). He also ardently advocated the study of
the pathology of the fetus and newborn infant, and published a two volume arbeit on
the subject (Ballantyne 1902–1904). In addition to his contributions in the develop-
ment of academic departments of obstetrics and gynecology in America and his
authoritative textbook of obstetrics (Williams 1903), Williams is noted for his role in
the development and popularization of prenatal care and the child heath movement
(Longo 1981; Williams 1910, 1915). It has been suggested that because of unprec-
edented advances in and emphasis upon gynecologic surgery, during the first half of
the twentieth century the visions of these two leaders were eclipsed (Dunn 2007).
In terms of the management of labor and delivery, contributions that helped to set
the stage for what was to follow were the mid-century graphical analysis of the
course of labor (Friedman 1955), and scoring of cervical dilatation for the elective
induction of labor (Bishop 1964). Again, beyond witnessing just a new era in clini-
cal medicine, the second half of the twentieth century may be regarded as a sweep-
ing renaissance in concepts, technology, and care. As a consequence of advances in
basic as well as clinical sciences, increasing knowledge with “translation” to the
bedside contributed to a number of aspects of health and the diagnosis and treatment
of disease. Among numerous diagnostic and therapeutic advances, treatment of the
fetus in utero as a patient became a practical reality, overcoming the view, held until
then, that the intrauterine sanctuary was inviolate (Rooth and Saugstad 1985; Saling
2006; Saling and Arabin 1988). With the ever increasing complexity and challenge
of providing optimum care for two patients, obstetrics has given birth to the field of
maternal–fetal medicine, a subspecialty further dividing within itself. As noted, dur-
ing the early- to mid-1930s Nicholson Eastman and colleagues had demonstrated
acidosis with elevated lactate levels in the umbilical cord blood of depressed neo-
nates (Eastman 1932; Eastman and McLane 1931).
Also in the 1950s, Virginia Apgar developed her scoring system in an attempt to
quantify the well-being of the newborn infant (Apgar 1953). With L. Stanley James
and coworkers, she quantified the degree of neonatal depression by correlating
umbilical cord blood pH with the Apgar score at 1 and 5 min (James et al. 1958).
Also during this era, advances in hematology contributed to the virtual elimination
of death from Rh disease (Bevis 1952; Diamond et al. 1951; Finn et al. 1961; Freda
and Gorman 1962; Liley 1961, 1963, 1964).
Thus, at mid-century, considerable emphasis in clinical obstetrics was beginning
to be placed on fetal assessment. Beyond clinical evaluation of “high” risk preg-
nancy, quasi-objective determinations included those of fetal size, height of the
uterine fundus, auscultation of fetal heart rate, and monitoring fetal movements.
15.5 Some Aspects of the Development of Maternal–Fetal Medicine 351

During the next decade, more objective measures of evaluating fetal well-being
became widely accepted. These included electronic monitoring of fetal heart rate
(EFM) (which allowed the continuous assessment of one aspect of the fetal state
during the course of labor; see below), and measurements of hormones such as
estriol, human chorionic gonadotropin, and somatomammotropin, and sampling of
amniotic fluid (amniocentesis) for measures of hemolytic pigments, pulmonary sur-
factant activity, cells for cytogenetic diagnosis and chromosomal analysis (Fuchs
et al. 1956–1957; Fuchs and Riis 1956; Tabor et al. 1986), and other constituents
(Harman 2009; Parer 1991). Increased facility in amniocentesis resulted from
advances in ultrasonic imaging.
In an attempt to determine its state of well-being, an additional important contri-
bution of fetal physiology to clinical practice in this era was that of sampling blood
directly from the fetus. In 1960, Erich Saling (Fig. 15.3d) of the Städt Frauenklinik
und Hebammenlehranstalt [City Clinic for Women and Institution for Midwife
Instruction], Berlin, developed the idea of obtaining a small aliquot of fetal blood
from the scalp or other presenting part during the course of labor. This approach
overcame centuries of ethical and emotional barriers. In his report, “New proce-
dures for examining the fetus during labor: introduction, technique, and basics,”
Saling described his pioneering approach to assess the fetal condition by obtaining
fetal scalp blood. He championed the concept of combining pH with abnormal fetal
heart rate pattern (Saling 1962). Subsequently, direct blood sampling of the fetal
umbilical cord for diagnosis and treatment was introduced, and the new field of
maternal–fetal medicine blossomed (Huntingford 1964; Morris and Beard 1965;
Nicolaides 1986; Saling and Schneider 1967). Saling has described the develop-
ment of his ideas along this line, much of this work originally being associated with
an attempt to diagnose and treat severe Rh incompatibility (Saling 1959, 1961b).
With the development of micro measurement techniques for blood sample analysis,
Saling published his report of obtaining fetal scalp blood during labor (Saling
1961a, 1962, 1966, 1981, 1985). Regarding its clinical utility, Saling maintained
that in cases of abnormal heart rate patterns fetal scalp blood analysis enables one
to establish the presence or absence of fetal hypoxemia or acidosis. In addition, such
analysis may help one to determine whether tocolysis (inhibition of uterine contrac-
tions) or rapid operative delivery are required (Saling 1985).
The introduction of this approach was not without criticism, and with current
advanced methodology the sampling of scalp blood has become uncommon. Saling
reported that his initial grant application to support these studies was rejected. The
reviewers believed fetal blood sampling to be “… ethically inadmissible to break
the taboo of the unborn infant,” and that the presence of the caput succedaneum
would eliminate the validity of the blood sample measurements (Saling 1985,
p. 109). Another whose voice was raised against this approach was that of Nicholas
Assali. He argued,
In recent years, we have witnessed an avalanche of papers written by various investigators
all exalting the value of fetal blood pH determination and proclaiming it as the key to the
mystery of intrauterine life. A rush has been set off to obtain blood samples from the fetal
caput, buttocks, feet, or any other accessible anatomical part with utter disregard for such
352 15 Additional Clinical Aspects of Developmental Physiology

accuracy prerequisites as anaerobic collection, knowledge of sample origin – whether arte-

rial or venous, stagnant or freely circulating, uncontaminated, and so forth. I am sure that
this is a temporary overenthusiasm on the part of clinical investigators, and that the pH fever
will subside as soon as we learn the true meaning of fetal blood pH and its relation to the
over-all picture of fetal acid–base balance and fetal-maternal interrelationship.
(Assali 1967, p. 325)

Following Saling’s introduction of the fetal scalp sampling technique it remained

for another two decades before blood samples were taken directly from the umbili-
cal vessels with the fetus in utero, e.g., percutaneous umbilical blood sampling
(Daffos et al. 1983).
This period also witnessed methods of culturing fetal cells from the amniotic
fluid (Jacobson and Barter 1967), and examining the chromosomes for infant gen-
der (Shettles 1956) or congenital abnormality. Discovery of the fetal-specific alpha-
fetoprotein (Bergstrand and Czar 1956; Gitlin and Boesman 1966), its elevation in
cases of neural tube defects (Brock and Sutcliffe 1972) and lower than normal levels
in fetuses with trisomy 21 (Merkatz et al. 1984), served as a marker for prenatal
screening. With the advent of electronic fetal heart rate (FHR) monitoring (see
below and Hon and Quilligan 1968), associations could be made between FHR pat-
terns and neonatal outcome. With introduction of the oxytocin challenge test (Ray
et al. 1972), the FHR response to uterine contractions could be assessed. With the
observation of an accelerated heart rate during spontaneous uterine contractions
(Lee et al. 1975; Trierweiler et al. 1976), this then served as a basis for the fetal
activity determination test (Lee et al. 1976), later renamed the non-stress test.
By allowing, for the first time, visualization of many aspects of fetal and placental
growth and development the introduction of ultrasonography of the pregnant woman
revolutionized obstetrics (Donald 1969, 1974; Holmes and Howry 1963). Among other
considerations, this permitted assessment of the fetal “biophysical profile,” e.g., mea-
surements of fetal breathing movements, gross body movements, muscular tone, reac-
tive heart rate, and amniotic fluid volume. To provide a dynamic assessment of
well-being, each of these variables could receive a score of 0 or 2 (Manning 1999;
Manning et al. 1980; Platt et al. 1983). Continued technological advances have allowed
detection of various indices of fetal growth (brain, biparietal of head, chest, abdominal
dimensions, and other descriptors), and a host of congenital anomalies. As a critical
component of a healthy pregnancy, and the long-term health and well-being of the
offspring, assessing fetal growth and defining its restriction has become an important
aspect of contemporary maternal–fetal medicine. Among many considerations,
A population reference is often established on the basis of a large sample size (ideally
representing the underlying population), with a study population that includes both low-risk
and high-risk pregnancies and both normal and abnormal perinatal outcomes. On the other
hand, a standard usually is based on low-risk pregnancies with a normal outcome. When the
“population reference” and the “standard” are applied to an individual fetus or infant, inter-
pretation of the findings differs. Use of a population reference will yield a relative fetal size in
relation to the total population; a standard will assess a fetal size in comparison to normally
grown fetuses. Thus, a standard may have more clinical utility than a population reference.
(Zhang et al. 2010, p. 522)
15.5 Some Aspects of the Development of Maternal–Fetal Medicine 353

As suggested in an editorial that accompanied this report, one should limit the
term “small for gestational age” to the fetus and newborn infant whose weight is
<10th percentile for population-based gestational age, and limit the designation of
“fetal growth restriction” (FGR) to those fetuses and infants whose growth is
believed to be less than optimal, “… recognizing that all SGA infants are not all
FGR, and that FGR infants are not all SGA, SGA would be based on growth percen-
tiles, and FGR would be based on evidence of pathologic growth” (Iams 2010,
p. 513). The assessment of the health and vitality by not only 2D, 3D, and 4D ultra-
sonography and echocardiography, but by sampling of fetal blood and tissues, cho-
rionic villus sampling, amniotic fluid biomarkers, and other measures, as well as
fetal therapy per se, has introduced a “brave new world” into the care and manage-
ment of the pregnant woman and her developing infant. Consideration of all of these
modalities is far beyond the limits of this essay. A striking aspect of these advance-
ments was the rapidity with which they occurred; with the emergence of maternal
fetal medicine and high risk perinatology, clinical obstetrics underwent a virtual
revolution. In view of the seemingly innumerable aspects and complexities of high
risk diagnosis and care demanded in the present-day, a number of papers and vol-
umes may help to guide the perplexed (Bianchi et al. 2000; Creasy et al. 2004;
Hansen and Sladek 1989; Harman 2009; Malcus 2004; Nageotte and Gilstrap 2009;
Queenan et al. 2010; Reece and Hobbins 1999, 2007; Salvadori 1981). In terms of
prenatal genetic diagnosis, two technologies have emerged that hold great promise.
Following in vitro fertilization and prior to transfer to the uterus, preimplantation
genetic diagnosis by removal of single cells from each blastocyst (day 3) can be
assessed for single gene disorders as well as chromosome abnormalities (Munné
2003). In addition, cell-free fragments of fetal DNA in the circulating blood of the
pregnant mother (Lo et al. 1997) can reveal molecular genetic disorders as specific
markers become available to differentiate DNA of the fetus from that of the mother
(Daniels et al. 2004; Kitzman et al. 2012; Lo 2005). In fact, recent reports demon-
strate that the entire genetic sequence of the fetus may be determined from a mater-
nal plasma sample (Fan et al. 2012) which allows diagnosis of inherited and de novo
genetic diseases. On one hand, such diagnostic ability will alert physicians to com-
mence treatment immediately following delivery, and even while the fetus is in
utero (Bianchi 2012). On the other hand, major practical and ethical questions con-
cern the manner in which prospective parents and physicians will use this genetic
information.
Perhaps surprisingly, despite innumerable advances and the increase in knowl-
edge, is that in so many areas our ignorance is profound. For instance, what is the
physiologic basis for the premature onset of labor, and why, despite our best efforts,
is the prevalence increasing? To what extent does brain damage-neuronal injury
occur during prenatal life, and what can we do to prevent/minimize this injury that
can result in catastrophe? How can we improve and optimize the incorporation of
advances in physiology and biomedical science into clinical practice? These are but
a few of the issues we must contemplate. In her 1992 “50-year overview…” of the
development of perinatal medicine, Mary Ellen Avery considered a number of
advances that have contributed to significant decreases in fetal and neonatal
354 15 Additional Clinical Aspects of Developmental Physiology

mortality and morbidity during the previous half-century. Among the lessons
learned in this recital she stressed that, “… we must build our interventions on the
relevant basic science. Where that does not exist, we must make every effort with
animal models and tissue culture methodology to unearth understanding of the
appropriate regulatory mechanisms that may need to be stimulated.” Avery con-
cluded that if we dedicate ourselves to it, the capacity exists to reduce infant mortal-
ity an additional 50 % (Avery 1992, pp. 49–50).

15.6 Pathology of the Fetus and Newborn

During the latter nineteenth and early twentieth centuries, the field of pathology
developed into a rather sophisticated science. It was not until near mid-nineteenth
century, however, that the pathology of the fetus or newborn received dedicated
attention. Edith Louise Potter (1901–1993) (Fig. 15.3e), of the University of
Chicago, changed that. Although seemingly rather removed from physiology, the
pathologic contributions of Potter and her associates helped to advance the under-
standing of physiology. Initially, because an administrator in the Chicago Department
of Health questioned the relation of the relatively high infant death rate to the gen-
eral sanitation and health of the city, he promoted the idea of autopsies to ascertain
cause of death. As pathologist at the Chicago Lying-in Hospital, Potter gained enor-
mous experience in this regard, performing over 10,000 infant necropsies in slightly
over three decades. With the Chairman of the Department of Obstetrics and
Gynecology, Fred Lyman Adair (1878–1972), in their 1940 report Fetal and
Neonatal Death, in which they analyzed 526 fetuses and infants dying from 1931 to
1938, the leading causes, accounting for almost one-third of the total deaths, were
anoxemia and intracranial hemorrhage (Potter and Adair 1940). Potter also pub-
lished a monograph on Rh and its relation to congenital hemolytic disease and intra-
group transfusion reactions (Potter 1947), and a major synthesis Pathology of the
fetus and newborn (Potter 1952). In preparing the volume for pediatricians, obstetri-
cians, as well as pathologists, she observed,
The description of the body of a dead infant is of no value as an isolated piece of informa-
tion, but if it is integrated with the various aspects of heredity, conception, development,
intrauterine and extrauterine environment and behavior it becomes part of an important
chronicle. Only by correlating all the facts of one case with all those of many cases can we
hope to elicit the etiologic factors responsible for clinical and pathologic observations… In
addition to the ultimate aim of the pathologist, of immediate practical importance is the
demonstration to the attending physician of the pathologic changes found in any fetus or
infant who fails to survive and the correlation of these findings with the symptoms observed
during life. When symptoms can be recognized as associated with specific pathologic pro-
cesses a great stride has been made toward their prevention and cure.
(Potter 1952, p. ix)

In 1946, Potter also reported on the findings of 20 infants with bilateral renal
agenesis (Potter 1946b) and abnormal facies (Potter 1946a). These infants also had
pulmonary hypoplasia, and later it was shown that this Potter’s syndrome was
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before her death, Potter reminisced on her career and numerous contributions to
perinatology (Potter 1989). From the Queen’s University and Royal Victoria
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contributions to pathology of the fetus and newborn, many of which had implica-
tions for physiology, such as differentiating between those infants born preterm and
those small for gestational age, was Peter Gruenwald (Gruenwald 1974). The con-
tributions to pathology of the placenta have been noted above (Benirschke and
Driscoll 1967; Fox 1978).

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Chapter 16
Bioethical Issues in Research on the Fetus
and Newborn Infant

16.1 An Awakening of Responsibility

As noted earlier in reference to both performance of studies on fetal endocrinology

and steroid metabolism, and in reference to other “experiments” for “pure science”
and the conduct of double-blinded clinical trials in attempting to improve survival
of very premature infants, a number of questions have arisen in regard to the ethics
of experimentation. With the lifesaving technologies of maintaining viability of pre-
mature infants at ever earlier ages, and the recognition that a high percentage of
such newborns face a life of neurologic disability, the debates can become intense.
A number of gifted individuals have addressed these issues, and there are no easy
answers.
Head of the Department of Experimental Medicine at Cambridge, and who, in
addition to his legacy in nutrition and metabolic balance, contributed in a significant
way to thinking on biomedical ethics, was Robert A. McCance. In his 1950
Presidential Address to the Section of Experimental Medicine and Therapeutics of
the Royal Society of Medicine, McCance explored a number of ethical aspects of
clinical investigation, as well as those of the basic sciences. He noted, “we should,
I think, for present purposes, regard anything done to a patient, which is not gener-
ally accepted as being for his direct therapeutic benefit or as contributing to the
diagnosis of his disease, as constituting an experiment, and falling, therefore, within
the scope of the term experimental medicine” (McCance 1951, p. 191). Several
years later, the Cambridge embryologist–endocrinologist Colin Russell Austin
(1914–2004) organized a conference on The mammalian fetus in vitro. Here, about
a dozen investigators addressed various aspects of maintaining the fetus ex utero,
both for scientific study and preservation of life. In addition to consideration of
marsupials and other species, these workers considered supporting the human fetus
as early as mid-gestation by extracorporeal oxygenation with artificial placentae or
other modalities. In addition to technical specifics, the participants considered
social, ethical, and legal issues (Austin 1973). In his summary essay “The Road
Ahead” (McCance 1973), McCance reviewed some of his thoughts from previous

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 367
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_16, © American Physiological Society 2013
368 16 Bioethical Issues in Research on the Fetus and Newborn Infant

work in the field (McCance 1951, 1959), presenting guidelines and benchmarks for
investigation of the human infant by both clinical investigators and basic scientists.
In addition, he pointed out the problem for the investigator/clinician of performing
experiments of “omission” (withholding treatment from a control), and those of
“commission” (such as performing procedures for which there is no obvious need).
Further, in asking “what…has gone wrong,” he pointed out the controversy with
physician–investigators, patients (or their parents), the law, and the “church” at odds
in confrontation, the problem compounded by sensationalism by the mass media.
McCance concluded that “tolerance and co-operation seem to be the best hope for
clinical research… Discord will get us nowhere, …let us make progress together”
(McCance 1973, pp. 364–366).
Ethical, legal, and moral aspects of clinical investigation have been considered
during much of the twentieth century, if not before (see anthology of Ladimer and
Newman 1963). However, it was at mid-century following the horrors of World War
II and the Nuremberg Trials, that ethical issues in regard to optimal care of patients
and what might be regarded as “experimentation” came into focus (for instance see
Freund 1965), and were vilified by some (Pappworth 1967). In considering “Some
Moral Dimensions of Medicine,” the philosopher Samuel Enoch Stumpf (1918–
1998) at Vanderbilt University in Nashville, TN observed.
Modern medicine has provoked some serious moral questions, not through malignant per-
versity, but because of the enormous momentum medical science has gained in the past few
decades…
There is the nagging question, What are the permissible limits and the proper conditions
for experimentation on human beings?…
These decisions cannot be postponed indefinitely. It is crucial at this historic juncture
that the enormity of the problem of discovering clear moral insights to delineate some
acceptable boundaries and limits to the use of human beings in research, should not produce
either an impatience or moral cynicism.
(Stumpf 1966, pp. 460–468)

16.2 The Emergence of Bioethics

During the early 1970s, the field of “bioethics,” (a term coined at this time; Potter
1970), came into being. Initially, its goal was to consider rather all-encompassing
interpretation of global issues of long-range environmental concerns that is a
“Bridge to the Future” of applying human values to biological knowledge (Potter
1971). Shortly thereafter, bioethics was redefined to address more specific dilem-
mas in clinical care (Hellegers 1977, 1978; Reich 1995). Of vital relevance to fetal
and neonatal biology and clinical care, was the founding in 1971 at Georgetown
University of the “Joseph and Rose Kennedy Institute for the Study of Human
Reproduction and Bioethics” (known as the Kennedy Institute) by that family
(Jonsen 2003). Its chief creator and first director, the Dutch Roman Catholic obste-
trician–gynecologist and fetal physiologist, André E. Hellegers (Fig. 16.1a), was a
16.2 The Emergence of Bioethics 369

Fig. 16.1 (a) Andre Hellegers (1926–1979). (b) Sir John Harold Peel (1904–2005). (c) David
Gordon Nathan. (d) Jerold F. Lucey

member of several Papal commissions, and known by some as “The Pope’s

Biologist” (Baker and McCullough 2009). Hellegers and colleagues at the Kennedy
Institute contributed to a number of areas of bioethical debates that involved the
fetus and newborn infant (for instance, see Hellegers 1977, 1978; Hellegers and
McCormick 1978), as well as other bioethical issues (Hellegers and Wakin 1978;
Reich 1995, 1999). Most recently, the term has been redefined further as “Bioscience
ethics,” to apply bioethics to technological/applied science (Pollard 2002, 2009). As
one reviewer has pointed out, with the growing awareness of global health care
issues, including access to care and outcomes, and ever increasing technological
advances, “…bioethics is becoming more responsive to a more global vision of
health care ethics” (Ross 2010, p. 457).
370 16 Bioethical Issues in Research on the Fetus and Newborn Infant

In terms of the ethics on fetal research and human experimentation, the early
1970s were a time of ferment. In addition to investigations on human fetuses at the
time of therapeutic abortion conducted in Scandinavia detailed above, several stud-
ies drew attention to this field of research. In an attempt to develop an “artificial
placenta” for the treatment of prematurely born infants who would be anticipated to
develop respiratory distress syndrome, in one study fetuses from 300 to 980 g (~17–
26 week gestation) were maintained on extracorporeal circulation (Chamberlain
1968). In another, the investigators demonstrated that attenuated rubella (German
measles) vaccine virus administered to the mother could cross the placenta to infect
the embryo/fetus at 7–15 weeks gestation (Vaheri et al. 1972). In yet another, the
authors established that at 15–17 weeks gestation, the placenta was an effective bar-
rier to 125I labeled glucagon crossing either from mother to fetus or in the reverse
direction (Adam et al. 1972). Following a 1970 accusation by a British member of
Parliament that live fetuses were being sold by abortion clinics for medical research
(Anonymous 1970), a special advisory group of the Royal College of Obstetricians
and Gynaecologists reported on the issues (Great Britain Dept. Health and Social
Security 1972). This dozen member advisory group, chaired by the surgeon-
gynecologist to the Queen, Sir John Peel (Fig. 16.1b) (Anonymous 2006), and
which included Geoffrey Dawes, considered “…the ethical, medical, social and
legal implications of using fetuses and fetal material for research.” A major issue the
panel addressed was that of fetal “viability,” concluding the minimal limit to be 20
weeks gestation (400–500 g). Included with a list of specific studies in which the
use of fetal tissue had been reported, in their concluding “Recommended Code of
Practice,” the advisory group urged that research be limited to: fetuses that were
pre-viable, living fetuses that weighed less than 300 g, that studies must be con-
ducted in departments directly related to a hospital, that they not be conducted for
more than “…two or three hours,” that there be no monetary exchange, and that all
studies be conducted only after specific sanction of the medical center ethical com-
mittee (Great Britain Dept. Health and Social Security 1972, pp. 1–15).

16.3 The Massachusetts Experience

In the USA, experimentation on living fetuses failed to attract the public attention
until the early 1970s, although the NIH had established internal policy guidelines
several years previously. Following the decision of the US Supreme Court “Roe vs.
Wade,” ruling that restrictive abortion statutes by states were unconstitutional (US
Supreme Court 1973), both the Executive Branch via the Department of Health,
Education, and Welfare (DHEW 1973), and the US Department of Health,
Education, and Welfare, addressed the issue of human experimentation in general,
and more specifically that of experimentation in the fetus.
In Massachusetts, several cases concerning fetal research resulted in legislation
with wide-ranging implications. One of these involved four Boston City Hospital
physicians accused of grave-robbing. Because pregnant women often must be
16.3 The Massachusetts Experience 371

treated for intrauterine infection, to determine the extent to which the commonly
used antibiotics, clindamycin and erythromycin, could be used in pregnant women
allergic to penicillin, in 1971 these physicians commenced a study on the manner in
which the antibiotics are metabolized by the pregnant woman and her fetus, com-
pared to that in the nonpregnant individual. Women who were to undergo therapeu-
tic abortion were given either a single or multiple doses of these antibiotics at
various times in advance of the procedure. In addition to obtaining maternal blood,
amniotic fluid and fetal tissues were sampled. The studies verified that pregnancy
significantly alters metabolism of these antibiotics, and that clindamycin crossed
the placenta and was concentrated in liver of the fetus more readily than did eryth-
romycin (Philipson et al. 1973). Publication of this study, which appeared in the
New England Journal of Medicine, inflamed Boston “right-to-lifers” who were
incensed about a study on women having therapeutic abortions, rejecting the ulti-
mate medical benefits of the investigation. In April 1974, a Boston grand jury
indicted the investigators for alleged violation of an 1814 Massachusetts law forbid-
ding grave-robbing. This case raised many of the same legal and social questions
brought up by accusation and conviction of manslaughter against another Boston
City Hospital physician who previously had performed a therapeutic termination of
pregnancy following appropriate hospital committee approval.
Similarly, a case was brought against a distinguished Harvard Medical School
hematologist, David Gordon Nathan (Fig. 16.1c), in his attempt to identify hemo-
globinopathies of the fetus in utero. Initial efforts in this regard were the detection
of sickle cell hemoglobin (beta chain anomalies; Kan et al. 1972), and thalassemia
(Cooley’s anemia, failure to produce adequate beta chains; Kan et al. 1974) in
fetuses undergoing elective termination of pregnancy. Soon, these investigators
used fetoscopy to sample fetal blood from the umbilical vessels to diagnose these
and related disorders (Alter et al. 1976; Chang et al. 1974). In several reports,
Nathan and colleagues have reviewed these contributions (Alter et al. 1977, 1980;
Alter and Nathan 1978; Nathan 1975a; Nathan et al. 1975, 1979; Sankaran and
Nathan 2010). In other essays, Nathan has considered the ethical issues of research
on the fetus, and the dilemma of developing the biomedical technologies for more
accurate and earlier diagnosis in those individuals most at risk (Nathan 1975b,
1976a; Nathan et al. 1975). For instance, in his “…Investigator’s view” of fetal
research in the Villanova Law Review, after surveying several aspects of the legal
and social issues, Nathan stressed the benefits of such research in saving lives. After
noting some of the obstacles and limitations, he concluded “…the work will move
forward, and as a result, the health and welfare of pregnant women and their fetuses
will be maintained and improved” (Nathan 1976b, p. 394). In his 1995 epic Genes,
Blood, and Courage…, Nathan recounted the life saga of a young patient with thal-
assemia for whom he cared, the challenges of early diagnosis and treatment, and the
manner in which advances in molecular diagnosis changed the nature of the ethical
debate (Nathan 1995). Among his many other honors, Nathan was awarded the
National Medal of Science (1990; Benz 2007).
A series of News and Comment reports in the journal Science discussed in
some detail the specifics of these cases (Culliton 1974a, b, 1975a, b), aspects of
372 16 Bioethical Issues in Research on the Fetus and Newborn Infant

the Massachusetts Law and its effect on fetal research (Culliton 1975c, d, e).
These essays also considered the response of a “National Commission for the
Protection of Human Subjects of Biomedical and Behavioral Research” (Culliton
1975f), and subsequent rulings by the Department of Health and Human Welfare
(Culliton 1975g). In essence, the litigation and rulings of these cases, combined
with public opinion and the rise of the “pro-life” movement, placed considerable
restrictions on fetal research, evoked fear in the hearts of investigators, and virtu-
ally eliminated this line of inquiry, regardless of medical or social benefits. Major
issues considered included definitions of “death,” fetal “viability,” the use of the
dead fetus, and the use of living fetus whether “non-viable,” “pre-viable,” or
“viable.” To a lesser extent, the ensuing dialogue/debates concerned issues of
long-term social consequences, the scope of responsibility for decision making,
the value of fetal life and “personhood,” and others. These, with advances in
neonatal intensive care, played a major role with development and advances in
the field of bioethics, establishment of hospital-based Institutional Review
Boards (IRBs), and a “brave new world” of complex cases and debate about their
management (Motulsky 1974a, b).

16.4 Later Developments

With rapid advances in the field of neonatal intensive care, in the 1970s, a vital
consideration was a series of ethical issues in the proper management of NICU
infants, particularly those less than 24–26 weeks of age, those with severe congeni-
tal malformations, and those that had evidence of long-term disability. Beyond the
immediacy of medical care per se, the optimal management of these infants raised
intellectual and emotional challenges. In concert with the rise of the bioethics move-
ments in general, Ross Laboratories, Columbus, OH, dedicated one of their Ross
Conferences on Pediatric Research to a consideration of Ethical dilemmas in cur-
rent obstetric and newborn care (Moore 1973). Over two dozen international lead-
ers met for several days to concentrate, as the chairwoman Mildred Stahlman
expressed it, “…on the questions to be asked rather than offering a variety of
answers to questions that were assumed, inferred or poorly understood” (Stahlman
1973, p. 12). The conferees considered a number of aspects of the ethical problems
and their limits, issues relating to specific diseases/conditions, and the process of
decision making (Moore 1973).
Almost concurrently, a 1974 conference of theologians, ethicists, anthropolo-
gists, perinatologist obstetricians, and neonatologist pediatricians, many from the
University of California San Francisco, considered a number of cases and sce-
narios associated with neonatal intensive care. These scholars proposed a moral
policy value, based upon responsibility, duty, and interest, as moral fields of force
to guide responsible actions (Jonsen et al. 1975). Later, Raymond Stanley Duff
(1923–1996) of Yale, critically emphasized the “doctor’s dilemma” in assessing
the importance of “close-up” ethics, relating to the immediacy of family feelings
and specific circumstances, and religious and related social factors, as opposed to
16.4 Later Developments 373

the dangers of “distant ethics,” referring to relative abstract principles, moral

ideologies, authority and rules, in guiding the management of infants with poor
prognosis (Duff 1987). As recognized by many, these infants present agonizing
decision making regarding “quality-of-life” issues. Stahlman described these as
“multifaceted, complex, and gut-wrenching for parents and care-givers alike”
(Stahlman 1990, p. 169). In concluding her review of “The future of ethical issues
in neonatology,” Stahlman observed,
Neonatal intensive care once demanded “caring intensively.” The demand is still there, as
imperative as ever, but caring has become old-fashioned and passé in the medical world of
business. God help us and our profession if we have forgotten how to care!
(Stahlman 1987, p. 273)

(For a more complete survey on these bioethical issues, see Duff and Campbell
1973, 1976; Hack and Fanaroff 1986, 1989; Nesbitt 1974; Pappworth 1967).
In a provocative essay, John D. Lantos, currently the director of the Children’s
Mercy Bioethics Center, Kansas City, Missouri, has reflected upon the “hidden
costs of success” of neonatal intensive care, financial, bioethical, and human (Lantos
2001). Lantos observed that this intensive care,
…has confronted, clashed with, and in some ways rearranged our consciousness. By devel-
oping ways to save the lives of a whole population of babies who once were through too
small to survive, it has changed the way we think about what babies demand from us as a
society and about what we owe to them
(Lantos 2001, p. 235)

Lantos continued, pointing out the limitations of intensive care, and the need to
place increased emphasis on comprehensive, preventative care for mothers at risk
by averting premature delivery. In addition, he noted the neglect of a society that
allows one-third of children to grow up in poverty, in “…a moral environment that
is both odd and compelling.” He concluded, with the thoughtful challenge to “…
think clearly about the choices we are making, and the choices we are thereby
rejecting” (Lantos 2001, p. 240).
In commenting upon these observations, Jerold Lucey (Fig. 16.1d) has empha-
sized the need for debate about neonatal intensive care, pointing out that in the USA
5,000 “fetal infants” who weigh 400–500 g are born each year, of which an average
of 12 % survive (20–40 % in some NICUs). He challenged the reader,
The world has never seen so many of these infants. What are their long-term prospects?
Sadly, we do not know. Everyone is worried about these so-called miracle babies. It’s time
for a major public debate on this subject.
(Lucey 2001, p. 313)

Lucey concluded by asking if America should not follow the lead of European
Countries in setting a birthweight and gestational age below which such intensive
care is not offered (Lucey 2001). Several years later, Lucey and colleagues reported
results of the serious morbidity problems of 4,172 “fetal infants” (birthweight 401–
500 g) with 17 % survival (Lucey et al. 2004). In an accompanying editorial, he
considered some of the dilemmas presented by intensive care for these “fetal
infants.” Lucey asked, “What can be done? The admission of ignorance is the begin-
ning of learning… We should admit how little we know, explain the present bleak
374 16 Bioethical Issues in Research on the Fetus and Newborn Infant

outlook for intact survival, and ask [parents] for their help.” He continued, stressing
the imperative to conduct randomized, controlled trials within an effective large
network of major clinical centers, with long-term follow-up for 10–12 years. In
conclusion, Lucey observed, “These infants are not ‘miracle babies’. We are neither
miracle workers nor ‘techno crazies’ …We need a new approach. If we don’t, we
will be asking the same questions 10 years from now” (Lucey 2004, p. 1819). For
his innumerable contributions to pediatrics and to life, in 2009, Lucey was honored
with the John Howland Award of the American Pediatric Society (Lucey 2010).
From mid-century onward, with increasing attention to bioethical issues in
human research, it has become no longer possible to conduct non-therapeutic fetal
studies even before therapeutic or elective abortion, and research on pregnant
women became restricted to avoid potential injury to the fetus. Thus, many investi-
gators looked to subhuman primates, particularly the Rhesus monkey, Macaca
mulatta, as an appropriate “model” for experimental studies. In the USA, the
National Center for Research Resources of the NIH in the early 1960s established
eight regional primate centers in a geographical distributed manner, each associated
with a University. Although many obvious species differences exist between Homo
sapiens and other primates, for many questions these centers proved to be of great
importance for the ability to perform carefully controlled studies (For a review, see
Cheek 1975). Although contributing greatly to an understanding of health and dis-
ease, investigative studies on primates have raised their own set of ethical issues,
many of which are unresolved.
As is becoming ever more apparent, decision making has become more complex
as clinical practice increasingly becomes directed by committee—mandated guide-
lines, outcomes research, and comparative-effectiveness analysis. Above all, by the
use of the optimal medical judgment as investigators, physician–scientists, and car-
ing clinicians, we must strive to treat patients and families with respect and concern
for their individual needs.

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Chapter 17
Textbooks, Monographs, and Other Volumes
on Fetal and Newborn Physiology

17.1 Volumes on Physiology of the Fetus and Newborn

Infant

For many basic science and clinical investigators, Geoffrey Dawes’ Foetal and
Neonatal Physiology (Dawes 1968) has served as the vade mecum par excelance.
A number of other such volumes have been published, latter ones of which were
stimulated by Dawes’ monograph. In 1920, the first work to appear on the subject,
The principles of ante-natal and post-natal child physiology. Pure and Applied, was
written by William Moses Feldman (1880–1939), physician and lecturer on child
physiology at the Infants Hospital, London. (See Table 17.1). In the preface,
Feldman observed that he prepared his work for “… students of physiology, and …
pediatric physicians, and all scientific persons interested in the study of children …
The task has not been an easy one, for I have had to travel far and wide in search of
my material, and have had to cross numerous deep and uncharted oceans of litera-
ture…” (Feldman 1920, p. vii). In 41 chapters covering almost 700 pages, Feldman
considered essentially every aspect of developmental physiology known at that
time. Part I addresses conception, developmental biology, fetal nutrition, respira-
tion, circulation, development of the nervous system, and the physiology of preg-
nancy. Part II considers the “Natal Stage” with the physiology of birth. In Part III,
Feldman reviews the “Post-Natal” stage of life, physiology of the neonatal period,
chemical composition of newborn tissues, the physiology of bone and the muscular
system, infant metabolism, the circulation, and related topics. Part IV is dedicated
to the physiology of the premature infant. Notable in Feldman’s work was his use of
mathematics, physics, and chemistry in considering physiological problems
(Feldman 1920).
As noted above, in the USA the anatomist William F. Windle pursued questions
relating to early development with emphasis on the circulation of the fetus, its oxy-
genation, and neural development. Based on his own work and early studies with
Joseph Barcroft, in 1940 Windle published the first American work devoted to this field,
Physiology of the fetus: origin and extent of function in prenatal life (Windle 1940).

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 379
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_17, © American Physiological Society 2013
380 17 Textbooks, Monographs, and Other Volumes on Fetal and Newborn Physiology

Table 17.1 Volumes on fetal and neonatal physiology

Authors/editors Year published Chapters Total pages
Feldman 1920 41 694
Windle 1940 25 249
Barclay, Franklin, and Prichard 1944 13 275
Smith 1945 13 312
Barcroft 1946 22+ 292
Smith 2nd Edition 1951 13 348
Smith 3rd Edition 1959 13 497
Dawes 1968 17+ 247
Stave 1970 35 1,097
Stave 2nd Edition 1970 40 851
Gevers and Ruys 1971 16 199
Hafez 1975 17 352
Smith and Nelson 4th Edition 1976 14 771
Beard and Nathanielsz 1976 26 542
Jones and Nathanielsza 1985 134 837
Battaglia and Meschia 1986 9 257
Gluckmana 1989 25 424
Polin and Fox 1992 190 1,884+
Hanson, Spencer, and Rodeck, Vol. 1 1993 19 438
Hanson, Spencer, Rodeck, and Walters, Vol. 2 1994 15 400
Thorburn and Harding 1994 36 468
Hanson, Spencer, and Rodeck, Vol. 3 1995 13 353
Harding, Jenkin, and Grant 1995 42 358
Brace, Hanson, and Rodeck, Vol. 4 1998 11 328
Polin and Fox 2nd Edition 1998 228 2,504+
Harding and Bocking 2001 12 284
Polin, Fox, and Abman 3rd Edition 2004 192 1,960+
Polin, Fox, and Abman 4th Edition 2011 185 2,038+
a
Proceedings of symposia

A student of history, he was familiar with the work of Thierry Wilhelm Preyer
(Preyer 1885). As noted in the Preface, although he planned originally “… to pro-
duce a more comprehensive review somewhat similar to that of Preyer,” he quickly
came to realize “… the futility of doing so within a single small volume” (Windle
1940, p. v). Nonetheless, in 15 chapters, Windle surveyed a wide vista, including
the fetal heart and its circulation, respiratory movements, blood, placental respira-
tory gas exchange, and other organ systems. In a comparison of textual material, it
is clear that both Barcroft’s later Researches on prenatal life… (Barcroft 1946), and
Dawes’ Foetal and neonatal physiology owe a great deal to Windle’s monograph,
particularly in regard to their historical perspective.
Five years after Windle, the pediatrician Clement A. Smith, Director of research
on the newborn at the Boston Lying-in Hospital and Harvard Medical School, pub-
lished The physiology of the newborn infant (Smith 1945). In his Foreword,
Frederick Carpenter Irving (1883–1957), Harvard professor of obstetrics, quoted a
17.1 Volumes on Physiology of the Fetus and Newborn Infant 381

previously unpublished and undated poem by the man of letters and Harvard profes-
sor of anatomy, Oliver Wendell Holmes (1809–1894),
So the stout fetus, kicking and alive,
Leaps from the fundus for his final dive.
Tired of the prison where his legs were curled,
He pants, like Rasselas, for a wider world.
No more to him their wonted joys afford
The fringed placenta and the knotted Cord.
(Smith 1945, p. vii)

Irving continued, “… never in the later life of man do such climatic changes
occur in so short a time. The onset of puberty is gradual, the period of senescence
consumes many years, even death itself for some may be a lingering event; a few
seconds, however, suffice for the first breath, the adequate expansion of the lungs,
and the adjustment of the circulation to pulmonary respiration …. Above all [obste-
tricians and pediatricians] should recognize that the newborn infant presents certain
problems of its own and that it is not merely a very young baby” (Irving 1945, p. vii).
In this volume, Smith considered a number of aspects of respiration, the circula-
tion, metabolism, renal function, and endocrinology from the standpoint of both the
fetus and newborn infant. In his introduction, he noted his deliberate eschewing of
a section on the nervous system, its knowledge being limited to the fetus as sur-
veyed by Windle (1940). Smith’s volume saw three subsequent editions (Smith
1951, 1959), the last of 1976 coedited with Nicholas M. Nelson of the Milton
Snavely Hershey Medical Center and Pennsylvania State University College of
Medicine (Smith and Nelson 1976). As noted earlier, Clement Smith developed one
of America’s earliest residency-postdoctoral programs for training investigative-
minded neonatologists. Under his mentorship more than four dozen gifted neona-
tologists progressed to academic centers throughout the country. As noted, Sir
Joseph Barcroft is said to have admonished Smith, “… remember that the essence
of the missionary enterprise … is to expel the people one by one” (Avery 1976, p.
857). In explaining why so many young pediatricians chose to train with him Smith
stated, “… if you were interested in babies and liked Boston, I was the only wheel
in town” (Personal Communication to Nicholas M. Nelson).
Reflecting the increasing subspecialization of biomedical science, in 1970, Uwe
Stave, of the University of Miami (and originally from the Universities of Hamburg
and Marburg), published a multiauthored, two volume work with 35 chapters by 40
authors, Perinatal physiology (Stave 1970). Eight years later, Stave published a sec-
ond edition, with 40 chapters by 48 authors (Stave 1978). These volumes also rec-
ognized the concept of “perinatal” biology and medicine, that is, the period
extending from the last few months of gestation (24 weeks onward) through the first
month of newborn life. As an aside, the term “perinatal,” to encompass the period
from the last several months of pregnancy through the first month of life, appears to
have originated in the 1930s (Reifarth 1934), although it did not come into common
use until mid-century (Peller 1943, 1944; Yaffe 1966).
In 1971, Rudolf Hans Gevers and Jan Hendrik Ruys of Leiden University in the
Netherlands, published the papers presented 2 years previously at a Boerhaave
382 17 Textbooks, Monographs, and Other Volumes on Fetal and Newborn Physiology

conference on the Physiology and pathology in the perinatal period. With its focus
chiefly on the fetus and newborn as patients, contributors considered the patho-
physiology of hypoxia, asphyxia, hypoglycemia, and related problems (Gevers and
Ruys 1971). The volume The mammalian fetus… edited by Elsayed Saad Eldin
Hafez of Wayne State University, Detroit was the product of a December 1973 sym-
posium and appeared in 1975 (Hafez 1975). With over 30 participants, the sympo-
sium considered “… recent advances in the control of fetal circulation, perinatal
respiratory physiology, fetal behavior, lipid substrates and fetal development, peri-
natal energy metabolism … biophysical techniques to study the fetus … intrauterine
detection of biochemical disorders and fetal malnutrition, embryological basis of
abnormal development … maternal health and fetal development, and fetal responses
to asphyxia” (Hafez 1975, p. ix). The editor and authors concluded in their recogni-
tion of critical gaps in our knowledge, such as “… preventive mechanisms of intra-
uterine hypoxia, necessary nutrients for fetal growth, physiological and molecular
mechanisms of intrauterine malnutrition and growth retardation, the effect and the
extent of intrauterine malnutrition on postnatal physical and mental growth, the
etiology of pregnancy toxemia, physiology of labor initiation, preventive mecha-
nisms of premature labor, and genetic and embryonic manipulations to correct cer-
tain hereditary and congenital anomalies” (Hafez 1975, pp. ix–x).
The following year appeared the compendium Fetal physiology and medicine,
the basis of perinatology by Richard William Beard (1931–2012) of St. Mary’s
Hospital Medical School, London, and Peter W. Nathanielsz, then at Cambridge
University (Beard and Nathanielsz 1976). Twenty six chapters, each by an authority
in his or her field, reviewed various aspects of fetal biology with emphasis on
metabolism and endocrinology, particularly that of interest to perinatologist obste-
tricians and neonatologist pediatricians. In the Preface, the editors emphasize the
convergence of disciplines required for deeper understanding of the subjects. In
commenting upon the rapidity at which the fields are advancing, they noted the need
for “… frequent revision and reissue …” (Beard and Nathanielsz 1976, p. v–vi).
Alas, with Beard’s death the latter goal was not realized.
A decade later in 1986, Frederick Camillo Battaglia and Giacomo Meschia, of
the University of Colorado, published An introduction to fetal physiology. In nine
chapters the authors guide the reader through intricacies of topics of their special
expertise, e.g., growth of the placenta and fetus, metabolism of oxygen, carbohy-
drates, and amino acids, and some nuances of uteroplacental blood flow, placental
exchange, and fetal respiratory and circulatory physiology. Foremost strengths of
the work are the lucid presentation of major concepts such as placental clearance
and metabolic balance, and the description of various experimental techniques, such
as the determination of metabolic fluxes of substrates across the placenta, and the
use of labeled microspheres to determine the distribution of fetal cardiac output and
organ blood flows. The authors synthesized many isolated facts into a fairly coher-
ent whole, placing these into a proper perspective as to biologic meaning. They also
reviewed several caveats regarding potential errors of the various methods, and the
interpretation of results (Battaglia and Meschia 1986).
17.1 Volumes on Physiology of the Fetus and Newborn Infant 383

With the exponential expansion of the field of developmental physiology, and the
virtual explosion of research and new information, in 1992, Richard Alan Polin,
Director of the Division of Neonatology at the Children’s Hospital of New York-
Presbyterian, Columbia University College of Physicians and Surgeons, and
William Willis Fox of the Division of Neonatology, Children’s Hospital of
Philadelphia and the University of Pennsylvania, published Fetal and neonatal
physiology, a two volume 1,884+ page compendium of 190 chapters by 283 authors
(Polin and Fox 1992). With the rapid advances in cellular and molecular biology,
and their contributions to understanding the physiology and pathophysiology of the
fetus and newborn infant, 1998 saw an enlarged second edition. In 2004 and 2011,
respectively, with Steven Herbert Abman, Director of Pediatric Heart Center, The
Children’s Hospital, Denver, and the University of Colorado, the third and fourth
editions were published (Polin et al. 2004, 2011). Without question, this work con-
tributes greatly to both the fundamental science and the clinical implications of a
broad array of topics in developmental physiology.
A further contribution was that of Mark Adrian Hanson and colleagues of the
University College London, who edited a four volume series on fetal and neonatal
physiology. By the editor’s admission, these are intermediate between a textbook
with breadth of coverage (which may lack critical analysis) and a group of review
articles (that may lack balance because of the biases of the authors). In a cohesive
set of reviews, the volumes address the circulation (vol. 1, Hanson et al. 1993),
breathing (vol. 2, Hanson et al. 1994), growth (vol. 3, Hanson et al. 1995), and the
body fluids and kidney function (vol. 4, Brace et al. 1998). Each volume addresses
the subject in terms of physiology, pathophysiology, and clinical applications, with
a number of authors and points of view for each subject area. The perinatal period,
with its transition from fetal to neonatal life, is such a critical juncture that consid-
eration of its multiple facets is most timely. Although one might confute the some-
what exclusive British perspective, of significance are the volumes’ stress on, and
illustration of, the considerable clinical applications of basic research.
An additional contribution of note, was the 1994 Textbook of fetal physiology
edited by Geoffrey D. Thorburn and Richard Harding of Monash University,
Melbourne. This contains 36 chapters contributed by 57 authors. Planned as a text-
book for undergraduate and graduate students, the volume served as references
work and a companion to the classical texts of physiology of the adult (Thorburn
and Harding 1994). That same year (1994), Richard Harding and colleagues orga-
nized a symposium on Hamilton Island, Queensland, Australia, to honor Geoffrey
D. Thorburn’s contributions to developmental physiology. Rather than a textbook
per se, the published volume comprises a series of papers on various aspects of this
topic (Harding et al. 1995). Several years later, Richard Harding with Alan D.
Bocking of the University of Western Ontario, Canada edited the volume Fetal
growth and development (Harding and Bocking 2001). The editors noted the pur-
pose of this compilation was “… to provide an account of the major factors involved
in the regulation of … growth and development [of the human fetus] and to review
the processes by which the fetus responds and adapts to a potentially stressful intra-
uterine environment” (Harding and Bocking 2001, p. ix). Presenting the material by
384 17 Textbooks, Monographs, and Other Volumes on Fetal and Newborn Physiology

organ systems, the editors rationalized this approach on the basis of “… the degree
to which … [systems] are important to the well-being of the fetus, the extent to
which they enable the fetus to withstand adverse intrauterine conditions, and its
ability to make the transition from intrauterine to extrauterine life” (Harding and
Bocking 2001, p. ix).
Table 17.1 lists these volumes by year of publication. A number of other volumes
have addressed the development, physiology, and pathophysiology of specific
organs and/or systems (Assali 1968; Assali and Brinkman 1972; Faber and
Thornburg 1983; Hytten and Leitch 1964; Jones 1988; Longo and Reneau 1978;
Timiras 1972; Wolstenholme and O’Connor 1965). Their review, however, is
beyond the scope of this essay.

17.2 The Josiah Macy, Jr. Foundation Conferences

on Gestation

A worthy contribution to the development of the field of fetal and neonatal physiol-
ogy, and reproduction in general, were the series of conferences held under the aegis
of the Josiah Macy, Jr. Foundation of New York. Established in 1930 by Kate Macy
Ladd (1863–1945) in memory of her father Josiah Macy, Jr. (ca. 1838–1876), who
had died at an early age of typhoid fever, commencing at mid-century the Foundation
concentrated its efforts on improving the education of physicians and other health
professionals. In conjunction with that objective, and, in part, stimulated by the suc-
cess of the Hixon Symposium on Cerebral mechanisms… (Jeffress 1951) noted
earlier, the Macy Foundation developed and supported an extensive program of con-
ferences and publications. Specifically during the 1950s, under the leadership of its
president Willard Cole Rappleye (1892–1976) and its medical director Frank
Fremont-Smith (1895–1974), the Foundation organized and supported a number of
focus groups which addressed topics believed to be compelling to the advancement
of medicine. Annually for 2½ days, each of these groups met over a 5 year period.
The five conferences on Gestation, held at the Nassau Tavern in Princeton, NJ from
1954 to 1958, brought together two dozen or so (limit 25) leading investigators from
a number of fields related to reproduction: embryologists, placentologists, anato-
mists, biochemists, pharmacologists, and physiologists, as well as obstetricians and
pediatricians who worked in these fields. From widely different backgrounds, these
individuals brought a multidisciplinary approach to the conference. Of the partici-
pants, a dozen and a half were “regular” members who attended all five annual
meetings. The others were “guests,” invited for one meeting or more. Referring to
themselves as the “Nassau Tavern Gestation Club,” during the proceedings only a
half-dozen or so of the attendees would present a formal paper, these being limited
to two or three per day. The majority of the time was devoted to discussion (Flexner
1955; Villee 1956, 1957, 1958, 1959).
17.3 New York Academy of Sciences Conferences on Fetal Homeostasis 385

In his opening remarks at a later conference Louis M. Hellman (1908–1990) of

the State University of New York, Downstate Medical Center, Brooklyn, recalled
regarding the initial Macy Conference. As soon as the initial speaker, Louis B.
Flexner, had read one sentence of his paper, “… the discussion began…, and nobody
else ever read anything thereafter.” Hellman also observed, “one of the most valu-
able rewards of these conferences is meeting people you never knew personally
before. The influence that these people and their friendship may have on your lives
is often striking” (Hellman, in Wynn 1965, p. 12).
A critical element to success of the Macy Conferences was the overriding phi-
losophy of the spokesperson Fremont-Smith, whose “experiments in communica-
tion,” encouraged the participants to experience a state of “free-floating security.”
Hopefully, in addition to the exchange of ideas, their interactions would stimulate
creativity and collaborations. Trained as a psychiatrist with a background in cyber-
netics, Fremont-Smith held that in major ways scientific advance was limited
because of a lack of communication, with the tendency for super-specialized scien-
tists in the several disciplines to talk past one another. In his introduction to each
conference he stressed,
We do not wish to compete with the scientific societies and journals which have established
formats for the presentation of material in their respective fields; rather, our aim … is to
offer a very informal forum for the exploration of one another’s views, feelings and atti-
tudes and to encourage the exchange of methods, concepts, and difficulties in an atmo-
sphere conducive to mutual understanding. Although the fertility of the multidiscipline
approach has been recognized by the scientific societies and journals … these organizations
have not yet been able to establish adequate coverage of interdiscipline communication.
(Fremont-Smith in Flexner 1955, pp. 7–8)

Fremont-Smith also emphasized the need to challenge “authority” in evaluating

ideas, concepts, and data, and the necessity of acknowledging unrecognized “blind
spots” and prejudices in ones thinking. These he called “… hidden obstructions to
communication” (Fremont-Smith in Villee 1956, p. 9). In addition to their benefit to
individual attendees, the Macy Conferences gained a wider audience by publication
of the proceedings. Following Louis B. Flexner editing transactions of the initial
conference, Claude Alvin Villee, Jr. (1917–2003) of Harvard Medical School,
edited the following four volumes. Striking for such volumes was inclusion of the
often free-wheeling, spontaneous, and dynamic discussions among the participants.
Joseph Dancis has written on the Gestation, series of Macy Conferences as “Classics
Revisited…” (Dancis 1994).

17.3 New York Academy of Sciences Conferences

on Fetal Homeostasis

Subsequently, Louis Hellman with Ralph M. Wynn of the State University of New
York, Downstate Medical Center, Brooklyn, organized a series of four conferences
on Fetal homeostasis. Also held at Princeton during the years 1964–1968, these
386 17 Textbooks, Monographs, and Other Volumes on Fetal and Newborn Physiology

were sponsored by the New York Academy of Sciences and its Interdisciplinary
Communications Program (Wynn 1965). Following a brief stint at the American
Institute of Biological Sciences, Fremont-Smith had moved to the Academy to head
this program. Again in his opening remarks, as with the Macy Conferences he
stressed the need for communication among scientists. He emphasized that with
new technologies and new insights, the frontiers of science were advancing in an
almost exponential fashion, and the problem of individual scientists being separated
and isolated by the formulated boundaries of departmental discipline. In addition to
the goal of providing a forum for communication, Fremont-Smith emphasized the
opportunity to thresh out problems and discuss them in-depth, and noted the privi-
lege of developing friendships and collaborations among investigators who ordinar-
ily might never meet one another. He pointed out that, although burdened by a
severe information crisis with data overload, the various branches of science are
branches of a single tree. Thus, while in our effort to understand the laws of nature,
we may look through different windows, each of which permits passage of only
certain rays of light, we must obtain our views through many windows (Fremont-
Smith in Wynn 1965).
In addition to presenting introductory remarks at each of the Conferences,
Fremont-Smith published several essays in which he expounded upon his philoso-
phy of the eminent need for interdisciplinary communication. For instance, in addi-
tion to the principles noted above, he stressed the need for scientists to engage in
“conversation” and platonic dialogue, in contrast to presenting formal lectures
(Fremont-Smith 1961). He also emphasized the critical role of philanthropic foun-
dations in supporting such interdisciplinary conferences and scholarships, in addi-
tion to grants-in-aid for innovative research (Fremont-Smith 1964). In a Letter to
the Editor of Science, following an earlier editorial challenging the mechanisms of
large meetings for bringing scientists together (Abelson 1965), Fremont-Smith
reviewed positive aspects of the small multiprofessional conferences he had orches-
trated, emphasizing the virtues of “special microenvironments” for scientific
exchange (Fremont-Smith 1965, p. 1669). In another essay, he considered the vir-
tues of repeated “interruption” of a speaker, as a means of contributing to the scien-
tific dialogue (Fremont-Smith 1969).
Although originally five conferences on Fetal homeostasis were planned, only
three subsequent New York Academy of Sciences Conferences were held (Wynn
1967, 1968, 1969). It was during the third conference, that for embryonic, fetal, and
newborn development, that the term “heterostasis” was suggested to be more fitting
than “homeostasis,” as a true steady-state does not exist. A reviewer of the third
volume observed,
This book is joyful reading for the weekend, or after dinner while in a comfortable chair.
There is so much fun in the midst of battle between participants! And what relentless, mer-
ciless interrogations by the participants, almost whenever a fact is claimed, or a new
hypothesis or theory is suggested. It is far more exciting than fictional novels immersed in
intrigue. This is a small convention of iconoclasts … The first formal speaker was to be M.
C. Chang … About 2 minutes after Dr. Chang’s presentation is underway, he is interrupted
with the first of dozens of questions and comments. From this point until the end of the
17.4 Essays in Perinatal Medicine 387

conference there are no longer any recorded attempts at formal presentations … Unlikely
insights into the collective personality of the meeting, as well as into some of the partici-
pants, are clearly gained by the reader, who cannot help but feel seated at the conference
table among the 25 obstetricians and reproduction scientists present. While the reading is easy and
enjoyable, the caliber of the clinical and scientific insights presented are the very highest.
(Fainstat 1969, p. 1290)

Regarding Conferences such as these, an important consideration is that of their

contributions to science in general, as well as to fetal-neonatal physiology, for their
role in building relationships and communication among scientists with differing
backgrounds, developing collaborations, and advancing the frontiers. Contemporary
meetings of this sort, such as the Gordon Research Conferences (www.grc.org),
Keystone Conferences (www.keystonesymposia.org), and groups such as the “No
Name Society” are modern day counterparts to these symposia and workshops from
bygone era.

17.4 Essays in Perinatal Medicine

As noted earlier, although not a volume per se, the series of over 100 essays on
“Perinatal Lessons from the Past” by Peter M. Dunn (Fig. 15.2c), of the University
of Bristol, is of relevance. These profiles of individuals and their contributions com-
mence with the Holy Bible, Hippocrates (460–375 BCE), and Aristotle (384–322
BCE), extend to the sixteenth century Royal midwife of France Louise Bourgeois
(1563–1636), the master of British Midwifery William Smellie (1697–1763), and
continue on to the Boston creator of modern neonatal medicine Clement A. Smith.
Currently, Dunn is preparing these collected papers for publication. Regarding the
background for these profiles, he has written,
On [my] retirement from clinical practice in 1988, the Editor of the Archives of Disease in
Childhood, Professor Malcolm Chiswick, invited me to prepare a series of biographical
essays concerning contributions made by some of the great doctors and scientists of the past
to the development of perinatal medicine. In the event, 108 biographical essays on distin-
guished men and women from 22 different countries were published in the journal between
1989 and 2009 …. Taken together in chronological order they provide ‘stepping stones’ in
the history of perinatal medicine from the days of Hippocrates right up to the recent explo-
sion of interest in this field.
The series of profiles had a number of purposes. Above all, it was planned to emphasise
that childbirth should not be divided into obstetrics/midwifery and paediatrics/nursing
working independently and divided at the cutting of the umbilical cord. Rather, there was a
need for continuous care of the fetus and the newborn by all the specialties working as a
team throughout. A second purpose was to draw attention to the truth of a remark made by
Sir Robert Hutchison [1871–1960] in 1931 during his Harveian Oration at the Royal
College of Physicians. He said: ‘Look round this room in which we are met. It is a noble
library indeed, but is it not also a mausoleum? And how many facts which men are at pres-
ent hunting for, and theories which are even now being put forward as new, lie already
buried in these shelves?’ (Hutchison 1931, p. 735). It gave me particular pleasure to draw
attention to current ‘discoveries’ that had, in fact, been made previously in the distant past.
The third purpose, subsidiary to the second, was to draw attention to certain themes that
388 17 Textbooks, Monographs, and Other Volumes on Fetal and Newborn Physiology

reappear a number of times throughout the series, such as the importance of maternal
posture during childbirth, the management of the umbilical cord at birth, and the impact that
rickets has had on obstetric practice. These themes have been interests of mine over the
years. While either controversial or neglected by modern practice they remain important
and I have derived encouragement from the knowledge that some of the great men of the
past have also thought so. Our forefathers, unencumbered by modern technology and pro-
tocol, had more time to think and to watch nature in action. We can still derive benefit from
the observations they made.
The choice of individual doctors, scientists and nurses about whom to write was not
easy as there were so many from whom to choose. The decision was helped by creating
some ground rules. First, the series would be based on western medicine. Second, an effort
was made to cover broadly the whole period from classical times right up to 1950. The
contributions of the last 60 years have been so numerous that they will require a second
series in the future. Thirdly, special favour was given to those individuals whose contribu-
tions have only recently been credited or indeed still await recognition. Fourthly, I confess
that being British and not a linguist, there was inevitably a strong bias towards those whose
contributions were available in English. Apologies are due to the many, many distinguished
individuals who have been omitted.
In order to bring the profiled individuals into sharper focus, their portraits have been
included when available together with extracts from their works so that the reader may gain
insight into the quality and style of their contributions. Some essays are shorter than others,
not because of the importance of the person concerned but because at first I was only per-
mitted one or at the most two pages of the Archives journal. In time, this limit was relaxed
to three or even four pages. In my choice of authors I have not only attempted to cover the
whole period of 2,400 years but also to cover different aspects of maternal, fetal and neona-
tal medicine. Some of the people chosen may not be as well known as they deserve to be.
It has been a pleasure to draw attention to their works.
The essays, originally published in random order in the Archives over the last twenty
years, have now been put in chronological order based on the year of birth of each doctor or
scientist. Many requests have been made by colleagues to publish the series in book form
and this exercise is currently in preparation under the title: Childbirth: perinatal lessons
from the past. Let me close with a quotation from Emerson: “…there is properly no History;
only Biography.”
(Letter from PMD to LDL, 23 February 2010)

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Chapter 18
Fetal “Breathing” in the 1970s, and Fetal
Heart Rate Analysis in the 1980s and Early
1990s

18.1 Early Studies of Fetal Breathing Movements

Since antiquity, mothers have been keenly aware of movements by the developing
fetus. For instance, Rebekah wife of Isaac noted that “… The children [Esau and
Jacob] struggled together within her” (Genesis 25:221). Even before taking advan-
tage of the chronically catheterized sheep preparation, Geoffrey Dawes rediscov-
ered the fact that the fetus “breathed” in utero. He recounted later that it was, in part,
because of “Mont” Liggins that he embarked upon this field of research. For it was
in the spring of 1970, that Liggins spent a 3 month sabbatical at the Nuffield
Institute. Several months earlier, in “acute” experiments in which the fetus, still
attached to the umbilical cord was placed in a warm saline bath, the Nuffield group
had observed respiratory-like activity (Dawes et al. 1972a). Although initially plan-
ning to explore some aspects of the role of insulin in the regulation of fetal meta-
bolic control, Liggins demonstrated to Dawes the value of the chronically
catheterized, unanaesthetized, preparation to study this activity (Dawes 1989, p. 6).
Concurrently, an American medical student, Harold Edward Fox from the University
of Rochester, spent the academic year, 1969–1970 working at the NIMR.
In Rochester, Fox had done some work with Mortimer G. Rosen (1931–1992),
studying the electrocorticogram (ECoG) of fetal guinea pigs and lambs. Fox, Chair
of Obstetrics and Gynecology at the Johns Hopkins University, states that seeing
Dawes’ recordings of the periodic nature of fetal breathing movements, were “…
reminiscent of the high voltage slow/low voltage fast periodicity of the … electro-
corticogram of the fetal lamb.” On several occasions Fox mentioned this to Dawes,
who, however, showed “minimal interest” in this association. Later, at a Friday
afternoon meeting in Dawes’ office for “sherry”, they were discussing preparations
for the following Monday’s chronic preparation. Dawes invited Fox to prepare his
electrodes to place in the fetal skull. “We did not have the sensitive biological ampli-
fiers necessary for EEG recording”, however working with Derek Wyatt over the

1
King James Version.

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 391
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_18, © American Physiological Society 2013
392 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

Fig. 18.1 (a) Harold E. Fox and Assistant. (b) Geoffrey Dawes with colleagues. (c) Jeffrey
Robinson

weekend, they prepared a system for recording. Fox has recalled, “On Monday,
I placed the electrodes and by Wednesday we were recording fetal electrocortico-
gram and correlating its activity to fetal respiratory movements. Subsequently, Dr.
Dawes supported my proposal to record fetal eye movements as well and we
embarked upon this several preparations later. I can remember Dr. Dawes’ excite-
ment when we sat down to review the polygraph records of fetal respiratory activity
and fetal ECoG for the first time. Sharing in the excitement of discovery is infec-
tious and I will be forever grateful.” Fox continued, “My year at Oxford had a pro-
found effect upon my career as did the mentoring of Dr. Dawes and Dr. Rosen”
(Letter from HEF to LDL, 19 May 2009) (Fig. 18.1a).
Previously, Dawes had recorded that near-term fetal lambs, delivered under
maternal regional or local anesthesia onto a warm table with intact umbilical cord,
did not normally breathe (Dawes 1968). About this same time, Dawes’ Nuffield
18.1 Early Studies of Fetal Breathing Movements 393

Institute colleague Derek Wyatt, had developed a new flowmeter with near zero
drift, that could be used to quantify fluid flow in the trachea, (Clark and Wyatt
1969), a technique used in later studies of blood flow (Wyatt 1984). With Fox,
Liggins, and colleagues, in the acute preparation Dawes reported bursts of irregular
rapid shallow, breathing-like movements that occurred for 35–40 % of the time
from 40 dpc (0.27 gestation) (Dawes et al. 1972a). In the chronically catheterized
preparation, particularly after 95 days (0.66 gestation), these breathing movements
were associated with low voltage high frequency (LVHF) electroencephalographic
activity and rapid eye movements (REM). In addition, he observed single, but
infrequent, deep inspiratory gasps “augmented breaths” or “sighs”, that occurred
~5 % of the time (Dawes et al. 1972a; see also Dawes and Robinson 1976).
In the chronically catheterized preparation, this REM-associated breathing activity
occurred almost solely in conjunction with LVHF ECoG, and was absent during the
high voltage low frequency (HVLF) state (Dawes et al. 1972a). In addition to nega-
tive pressures in the trachea that reached about ~25 mmHg, in many instances these
respiratory movements also were associated with major fluctuations in heart rate
and blood pressure. Despite the vigor of this respiratory activity, this was associated
with comparatively small changes in tracheal fluid flow or pulmonary volume.
These workers also noted that although section of the vagus nerves failed to alter
fetal breathing, it was abolished by general anesthesia (Dawes et al. 1972a). As an
aside, although this report is Dawes’ most highly cited publication, it had been
rejected by Nature, for a “… lack of general interest” (Liggins 1998, p. 122). He
also reported such respiratory activity in guinea pigs (Dawes et al. 1972b). In sheep,
a prominent diurnal activity was demonstrated with a peak in rapid, irregular breath-
ing, tracheal volume flow, and LVHF ECoG state at from 1800 to 2400 h (Dawes
and Robinson 1976).
Of relevance, in 1972 Edward James “Ted” Quilligan (Fig. 18.2b), at Yale
University, published a report on their studies on the electroencephalogram of the
near-term fetus, in which they described the cycling of high voltage low frequency
activity with low voltage high frequency, rapid eye movement sleep state (Jost et al.
1972). Regarding their early studies, Quilligan, more recently at the University of
California Irvine, has written,
In the late 1960s, our lab at Yale was doing chronic preps to study the fetal heart rate and
acid base balance of sheep in labor. Each medical student at Yale did a project and I had this
bright young student Gilbert Jost indicate he wanted to study the fetal EEG. We devised a
preparation which is exactly the same prep that Geoffrey [later] used. [Dawes] came to my
lab in either 1968 or early 1969, saw the prep and was very interested in it. The study was
finished in 1969, because I left and moved to the University of Southern California. Gill
Jost wanted to publish the paper in a neurologic journal, but it got rejected by two journals,
I believe, and thus was late being published in the AJOG (Jost et al. 1972). I believe from
Dr. Fox’s letter he joined the Nuffield group in 1969. This would be the time their lab
started EEG recording and would be after the time Geoffrey had seen our preparation.
I thought Geoffrey had mentioned this in a publication but cannot find that publication.
(Letter from EJQ to LDL, 24 February 2010)

In reference to studies at the Nuffield Institute, Liggins has recorded that during
his 1969 sabbatical with Dawes at the Institute, his “… adventure of the morning
394 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

routine of carrying the sheep up the winding staircase. Some of the sheep were
pregnant, some were not. The habit had been to make the distinction when the ewe
was anesthetized and the abdomen opened, clearly wasteful of time and money. My
legacy to the Institute was the demonstration of the art of abdominal palpation,
whereby the presence of a foetus could be determined before the ascent up the stairs
began” (Liggins 1998, p. 118).
As noted elsewhere, in 1970 the Nuffield Institute moved from the “Tower of
the Winds” to its new quarters on Headington Road. Jeffrey Samuel Robinson
(Fig. 18.1c), now at the University of Adelaide, Australia, recalls his first experi-
ment with Dawes,
My first fetal physiology experiment was conducted … in the new building of the Nuffield
Institute. Every piece of equipment had been dismantled and reassembled …. All seemed
to go well until Geoffrey came in to lead the experiment – an acute one with an exteriorised
fetus in a saline bath. Geoffrey checked the temperature of the bath with his hand and was
blown across the room by an electric shock as the current of heating element in the bath was
going through the saline solution – the wiring had been connected incorrectly. Geoffrey
recovered, the wiring was corrected and the experiment progressed well. It was one of the
few experiments that he actually led while I was there. Geoffrey … later came to assist me
with a chronic fetal sheep operation. He rapidly became bored with the surgery which had
to be more careful as recovery and sterility were important. However, when we were short
of people he came and assisted a few times.
Computing was considered after he set me the task of analysing heart rate variability.
When I said I could not do it from the printed records that ran for many days, he took over
and locked the door of his room to analyse it himself. Three days later, he came into my
office to agree and said that he had just taken the decision to purchase the Institute’s first
computer. I subsequently wrote the first program to record heart rate and blood pressure
from fetal sheep. I was allocated 4k of memory for the program, recording and printing out
the result. The data was then erased and the next set collected and printed out. Later analysis
required re-entering the data by hand into statistical packages. Geoffrey progressively
expanded the recording of heart rate leading to his program that is still used in Oxford.
(Letter from JSR to LDL, 17 April 2009)

Dawes’ series of studies of fetal breathing movements confirmed the late nine-
teenth and early twentieth century findings of several German workers. Both
Bernhard Sigismund Schultze (1827–1919) of the University of Jena (Schultze
1871) and Johann Friedrich Ahlfeld (1843–1929) at Marburg (Ahlfeld 1888), had
observed fetal respiratory-like activity in women near-term, as these breathing
movements could be seen through the abdominal wall. Ahlfeld argued that because
this activity was necessary to life following birth, it was reasonable that such activ-
ity precede birth. As an aside, he noted that newborn infants swallow and suck their
thumb, and he believed he saw evidence of this in the fetus, as well as kicking move-
ments. One of Ahlfeld’s students also published an early tracing of these in utero
fetal movements transmitted to the maternal abdominal wall (Weber 1888). In a
subsequent report, with a glass funnel placed on the mother’s abdomen and a kymo-
graph, Ahlfeld published remarkable records of fetal chest movements that aver-
aged 54 per min. He also recorded periods of very rapid breathing followed by
apnea, an observation he noted that also may occur in the newborn (Ahlfeld 1905).
Soon, these movements were confirmed by others (Reifferscheid 1911), who with
18.1 Early Studies of Fetal Breathing Movements 395

Ahlfeld, maintained that fetal respiration was not associated with aspiration of
amniotic fluid into its trachea and bronchi. Other observers, however, held that these
movements were a consequence of external tactile or thermal stimulation, thus
rejecting Ahlfeld’s thesis (Runge 1905). In addition, the fact that radiopaque con-
trast material injected into the amniotic fluid, later could be seen in the fetal gut, but
not the lungs, caused some to discount the fact, or importance of, fetal respiratory-
like activity. Ahlfeld also wrote on amniotic fluid and its formation, noting that it
could not be accounted for by fetal urination, but rather was formed by secretion of
the amniotic membranes (Ahlfeld 1911). Regarding these early studies, Robert
Clair Goodlin, formerly of Stanford University and the University of California
Davis, has written,
I tried to get Dawes to refer to Ahlfeld’s multiple reports on human fetal breathing, but he
declined to do so, claiming they were ‘anecdotal’. The same with fetal heart rate beat-to-
beat variability. He very much wanted to be ‘Mr. Fetal Physiologist’. Given that I was work-
ing with Abe Rudolph, I found Dawes’ demeanor hard to accept.
(Letter from RCG to LDL, 10 June 2009)

In his 1913 text, Principles and practice of obstetrics, Joseph B. DeLee, of

Chicago wrote that “the evidences of life of the fetus in utero form an interesting
study … The fetus moves its limbs and body from the earliest months, and the
movements are audible and palpable from the fifteenth week … The child has peri-
ods of sleep, of rest, and of activity.” DeLee continued “another phenomenon, not
so common, and more uncertain of diagnosis, is the respiratory action of the child
in utero. If one carefully observes the umbilical region of a thin woman, pregnant
near term, one may discover fine rising and falling movements of the abdominal
wall. They occur 60 to 80 a minute, are intermittent, and are most pronounced in the
region of the child’s chest” (De Lee 1913, pp. 58–59).
In the mid-1930s, Franklin Faust Snyder (1897–1992), of the Department of
Obstetrics, and Morris Rosenfeld (1906–1968), of the Department of Pharmacology
and Experimental Therapeutics, at the Johns Hopkins University, demonstrated that
contrary to the idea commonly held that the fetus was apneic, fetal cats, guinea
pigs, and rabbits showed considerable respiratory activity. Abolished by both
hypoxia and hypocapnia, hypercapnia did not stimulate this activity significantly
(Snyder and Rosenfeld 1937a). On the basis of the observed responses to hypoxia,
the authors concluded that carotid body chemoreception and activation was unim-
portant during fetal life, a fact subsequently confirmed by Dawes et al. (1972a) and
others (Jansen et al. 1981). In an associated study, Snyder and Rosenfeld demon-
strated similar respiratory-like activity in the human fetus near-term, and suggested
that fetal aspiration of tracheal fluid contributed to dilatation of the future air pas-
sages, with development of the lungs and their alveoli. They also noted that in some
instances cells, meconium, and other debris could be found within the potential air
spaces, a possible route for the introduction of infection (Snyder and Rosenfeld
1937b). In yet another study, these authors demonstrated that India ink injected into
the amniotic cavity soon appeared within the lungs of those fetuses that displayed
respiratory movements, but not in those that were quiescent. Again they stressed
that such activity plays an important role in the dilatation of the future air passages
(Snyder and Rosenfeld 1937c).
396 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

Joseph Barcroft, in his observations in premature, exteriorized fetal lambs, con-

cluded that from 40 to 60 dpc, although fetal breathing-like activity normally was
not present, it could be elicited by tactile stimulation of the face. He reported that
from 60 dpc onward, the animals showed no response, this respiratory activity com-
mencing only at the time of birth (Barcroft 1946, p. 260). In his Physiology of the
fetus…, Windle dedicated a chapter (VI) to breathing-like activity in the developing
fetus, noting the possibility that this represented “practice” in preparation for breath-
ing after birth. Nonetheless, Windle held, as did Barcroft, that for, the most part,
such respiratory movements were initiated by hypoxia and/or hypercapnia stimulat-
ing the brainstem respiratory center, following its maturation during the latter part
of gestation (Windle 1940, p. 78ff). In his Physiology of the newborn infant, Clement
A. Smith summarized some historical aspects of fetal respiratory movements (Smith
1945), much of which was based on a previous review (Bonar et al. 1938). For sev-
eral species, Davenport Hooker (1887–1965) of the University of Pittsburgh, also
has given a valuable account of the genesis of respiratory and other movements in
the developing fetus (Hooker 1952). Following his analysis of the interrelations of
structural (neuronal pathways) and function (the several types of movements),
Hooker concluded,
… it is evident that each class of vertebrates, perhaps each order, genus, and species, exhib-
its characteristics in the development of behavior which belong to that subdivision of ani-
mals alone. Nevertheless, each form of activity shown by any fetal organism is a step in
normal development, hence a step in preparation for postnatal behavioral capabilities.
Furthermore, there is a tendency for voluntary acts, where and when they appear, to develop
in a sequence based upon the earlier reflexogenic sequence of prenatal life. This is particu-
larly well demonstrated in the case of human behavior. The frontiers of research in the
development of fetal activity are by no means closed.
(Hooker 1952, p. 120)

Several decades later, Michael J. Purves and colleagues at Bristol University,

explored aspects of neural respiratory activity in the fetal and neonatal lamb
(Bystrzycka et al. 1975; Ponte and Purves 1973).
In contrast, with diaphragmatic electromyographic recordings, others soon dem-
onstrated that in association with diaphragmatic activation, tracheal pressure decreased
and small a volume of tracheal fluid flowed inward (~ 0.5 ml per breath). Additionally
in sheep, during the latter third of gestation from 100 dpc to term, the pattern of respi-
ratory activity was shown to change, with a significant increase in the relatively slow
(1–2 per min) mode of regular breathing (from ~6 to ~17 % of time), with a concomi-
tant decrease in rapid breathing (~60 per min) (from ~19 to 3 % of time) (Maloney
et al. 1975). In humans, by use of continuous Doppler ultrasound instrumentation, the
Nuffield Institute group soon demonstrated fetal breathing movements (Boyce et al.
1976). This discovery gave rise to the promise of the clinical application of FBM in
assessment of fetal well being. Dawes and Robinson concluded that near term, fetal
breathing movements with the LVHF ECoG state to be present about 55 and 70 % of
time in sheep and humans, respectively (Dawes and Robinson 1976).
In a later review of this topic, Dawes reported unpublished observations from his
laboratory on several phenomena. These included almost continuous diaphragmatic
electromyography activity, with only intermittent contraction of intercostal muscles
18.1 Early Studies of Fetal Breathing Movements 397

prior to differentiation of the diaphragm. He also stated that following fetal ECoG
differentiation, diaphragmatic EMG activity became intermittent, correlating with
transthoracic pressure changes. Dawes concluded that the mechanisms which regu-
late fetal breathing develop progressively and concurrently with general growth and
development (Dawes 1980, p. 5). In terms of the ontogeny of respiratory-like and
diaphragmatic activity, these workers reported that from mid-gestation onwards to
~110 dpc (0.75 gestation) in the sheep, breathing movements were almost continuous,
becoming more periodic from 130 dpc to term, as reflected by diaphragmatic
electromyographic activity (Bowes et al. 1981). Subsequently, the Dawes group
demonstrated three distinct age-related patterns of the interrelations of breathing
movements, ECoG activity, and rapid eye and neck movements. For instance, from
95 to 106 dpc, FBM, LVHF ECoG state, ocular and nuchal activity were relatively
continuous. From 107 dpc FBM became episotic, in association with LVHF, rapid
eye movement, and nuchal muscle activity. Then from 120 dpc onward the ECoG
was differentiated clearly into LVHF and HVLF states, with FBM and rapid eye and
nuchal movements occurring almost exclusively during the former (Clewlow et al.
1983). Dawes also confirmed that these activities become episotic, and with devel-
opment of cyclicity of the electrocorticogram, breathing movements occurred solely
during the LVHF state (Dalton et al. 1983).
To determine the mechanisms of regulation of fetal respiratory-like activity, the
Oxford group and others used several approaches. For instance, they demonstrated
in sheep during the last third of gestation, that breathing activity was inhibited
significantly or abolished by hypoxia, but was stimulated by hypercapnia.
Concomitantly, hypoxia reduced the proportion of time occupied by LVHF ECoG
activity, while this increased in response to hypercapnia (Boddy et al. 1974a, b).
Also in sheep, fetal breathing-like activity occurred during rapid eye movement
LVHF ECoG state, but not during HVLF. With use of a double-wall plexiglass win-
dow, these associations also were demonstrated visually (Rigatto et al. 1986).
Further, because E-type prostaglandins (PGs) used to maintain ductus arteriosus
patency in newborn infants with certain forms of congenital heart disease were
associated with apneic spells (Olley et al. 1976), it was postulated that prostaglan-
dins were involved in regulating respiratory-like activity. Indeed, in near-term fetal
sheep, intravascular infusion of a prostaglandin synthase inhibitor was associated
with an increase in breathing movements from 38 to 69 % of the time, including
during the HVLF state. In addition, prostaglandin inhibition showed an increase in
respiratory amplitude (Kitterman et al. 1979), and such prostaglandin-mediated
inhibition also stimulated respiratory movements independent of sleep state (Jansen
et al. 1984). In a further study in the near-term fetal sheep, these workers demon-
strated that with infusion of PGE2, FBM decreased to 10 % of control. In contrast,
infusion of PGF2α or endoperoxide analogues resulted in breathing movements
decreasing only to 64–69 % of control (Kitterman et al. 1983). In addition to con-
firming the role of PGs in inhibiting FBM in brain stem sectioned fetuses, Brian
John Koos, working as a graduate student with Dawes, demonstrated that the PGs
act centrally in the medulla or lower pons to modulate breathing (Koos 1985). Koos
also showed that despite their abolition by acute hypoxia, in animals maintained
398 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

chronically hypoxemic for 6 days, breathing-like movements returned to normal

(Koos et al. 1988). Geoffrey Thorburn argued that the placenta and its secretion of
PGE2 alters fetal peripheral chemoreceptor activity in response to arterial blood gas
values, and thus modulates breathing movements. He also suggested that in the
newborn, it is the rapid fall in PGE2 concentrations following delivery that plays a
critical role in both the initiation of breathing and reabsorption of lung liquid
(Thorburn 1995).
Breathing movements also were shown to be relatively unaffected by peripheral
arterial chemoreceptor input (Dawes et al. 1972a), and not essential to the establish-
ment of breathing at birth (Jansen et al. 1981). In an effort to elucidate the central
regulatory mechanisms of FBM, another approach was to examine the association
of LVHF ECoG activity with breathing movements following transection of the
brainstem (Dawes et al. 1981c, 1983). Several years previously, Liggins had shown
that following fetal spinal cord transection at C2–C3 (above the phrenic nucleus),
lung development was reduced significantly (38 % decrease in weight and 55 %
decrease in distensibility) (Liggins et al. 1981). Dawes and colleagues then demon-
strated that fetal brainstem section above the pons, at the level of the superior col-
liculus, was followed by continuous FBM, with dissociation of “breathing” from
electrocortical activity. In control fetuses, in contrast to the decrease in FBM rate
and amplitude seen normally in response to hypoxia, FBM increased following
suprapontine section. When sectioned more rostrally, this dissociation between
breathing movements and ECoG persisted, and the baroreflex sensitivity was
increased. These experiments established that higher medullary centers exert an
inhibitory influence on FBM (Dawes 1984; Dawes et al. 1983). By use of ultraso-
nography in humans, Heinz Friedrich Rudolf Prechtl at the University of Groningen,
The Netherlands, (currently at the University of Graz, Austria), reported on a num-
ber of aspects of the patterns of fetal body movements, defining several distinct
behavioral states (Prechtl 1974, 1984). He established with colleagues that the near-
term human also responds to external vibroacoustic stimuli, suggesting an awake
state (Gagnon et al. 1986, 1987; de Vries et al. 1982, 1985, 1987, 1988).

18.2 Fetal Breathing in Humans

These findings in sheep opened the way for studies of fetal behavior both in sheep
and, with the use of ultrasonography, in humans. For instance, Dawes in his 1987
James Alexander Frederick Stevenson (1918–1971) Memorial Lecture at the
University of Western Ontario, Ontario, Canada, stressed the increasing complexity
of neural functional integration during the course of development, synthesizing rel-
evant studies in neurobiology (Fitzgerald and Koltzenburg 1986), with the evidence
for fetal perception of pain, diurnal rhythms, sleep states, breathing-like activity and
body movements (Dawes 1988, 1994). During the following decade, studies on fetal
breathing patterns, and their associations with related physiologic phenomena
including behavior, neurophysiology, pulmonary mechanics, growth of lung and
18.2 Fetal Breathing in Humans 399

Fig. 18.2 (a) John E. Patrick (1942–1989). (b) Edward H. Hon (1917–2006), Fred Kubli (1930–
1987), and Edward J. Quilligan (1964). (c) Roberto Caldeyro-Barcia (1921–1996)

other organs, and cardiovascular dynamics, would occupy much of his energy. In
humans, the use of Doppler ultrasonography and linear-array real time imaging to
detect fetal breathing and body movements gave hope of its use in diagnosing fetal
hypoxia/asphyxia; however, this promise remains to be fulfilled (Boddy et al. 1974b,
1976; Boddy and Dawes 1975; Boyce et al. 1976; Chapman and Dawes 1978;
Dalton et al. 1977; Dawes 1977a, b, 1979, 1984; Dawes and Robinson 1976;
Duenhoelter and Pritchard 1977; Patrick 1980; Patrick et al. 1978; and others). In
the human, in addition to breathing-like activity, fetal body movements soon came
to be appreciated as an index of fetal well-being (Timor-Tritsch et al. 1978a, b;
Walters 1964).
John Elgin Patrick (1942–1989) (Fig. 18.2a), of the University of Western
Ontario, one of Dawes’ postdoctoral fellows, was particularly active in quantifying
400 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

fetal activity in the human. For instance, in the healthy fetus at 34–35 weeks gesta-
tion, both FBM and body movements were shown to increase several hours follow-
ing meals, presumably reflecting plasma glucose levels (Patrick et al. 1978). In
patients near-term, FBM occurred ~26 % of the time, but in association with labor
decreased to ~8 % during latent-phase, and were essentially absent (~1 % of time)
during active labor (p < 0.001). Although both FBM, in association with body move-
ments, and heart rate variability occurred during a control period, during the first
stage of labor the latter persisted despite absence of FBM (see below; Richardson
et al. 1979). Near term, a circadian pattern of FBM activity was observed, with the
peak between 2100 and 0100 h (Patrick et al. 1982). Such a circadian rhythm also
occurred for heart rate acceleration patterns (Patrick et al. 1984). In 1980, Patrick
reported on several aspects of fetal breathing in the human (Patrick et al. 1980;
Patrick and Challis 1980). In addition, he edited a special issue of the journal
Seminars in perinatology (volume 5, number 4), which summarized a number of
aspects of fetal breathing movements in human pregnancy, including their measure-
ment by various techniques, their relations to blood glucose and oxygen levels, and
related factors (Patrick 1980).
In perspective, to a great measure the work of Dawes and his associates on fetal
breathing and body movements stimulated the work of others. In toto, it suggests an
important role for this activity in fetal growth and development, serving as an illus-
tration of development of an activity-dependent mechanism in the central nervous
system. As a demonstration of their importance, fetal behavioral states also have
been demonstrated in the guinea pig (Umans et al. 1985), rhesus monkey (Martin
et al. 1974), and baboon (Grieve et al. 1994). With hypoxia and/or asphyxia, the
alterations in behavioral state are a function of gestational age, the severity and
duration of hypoxia, and its association with progressive academia (Bocking 1992).
In response to hypoxia, attenuation of fetal activity may be important in conserving
oxygen consumption and energy expenditure. Clearly, gestational age, time of day,
relation to maternal food intake, uterine activity, and other factors are important in
the evaluation of fetal movements. Thus, clinical assessment of the “nonstress test”
(Evertson et al. 1979) and “Biophysical Profile” (Manning 1999; Manning et al.
1985, 1993) in which fetal movements are evaluated, need to be interpreted care-
fully in high risk obstetrical patients, with the appreciation that loss or attenuation
of this activity may represent impending catastrophe.
In 1973, a new dimension was brought to the Nuffield Institute, when Geoffrey
Thorburn, on sabbatical leave from the University of Melbourne, and who had been
working for a year there under the aegis of a Medical Research Council Program
grant, joined the Institute staff. A gifted endocrinologist, Thorburn was joined by
John Challis and Jeffrey S. Robinson. During a 5 year period at the Institute, this trio
was to revitalize many aspects of an understanding of fetal endocrinology, particu-
larly that of the hypothalamic–pituitary–adrenal axis. As noted in regards to fetal
breathing, Thorburn conducted a series of studies demonstrating the role of placen-
tal prostaglandin E2 (PGE2), and also adenosine, in inhibiting fetal breathing move-
ments (see Thorburn 1995 for review).
18.2 Fetal Breathing in Humans 401

In recalling Thorburn’s years at the Nuffield Institute Jeffrey Robinson noted,

Both Geoffreys were amazing people to work for, but their style was very different. Geoffrey
Thorburn was known as the “Big G”. He was always speculating and designing new experi-
ments. Our sessions in the White Hart, the local pub could solve any problem in fetal physi-
ology and each time we seemed certain that we had got the final answer. The Big G was
very interested in the trigger for parturition. He was talking on the topic at a Ciba
Symposium, as was my other co-worker of the time, John Challis. I was the junior back in
Oxford. I was testing [the effects of] administration of arachidonic acid or prostaglandins
given locally into the uterus. Our hypothesis was that adding arachidonic acid would lead
to parturition – Geoff was anxious the present the “success” of this experiment. Therefore
there were a series of phone calls each day for an update of the state of the pregnant mon-
keys – they did not go into labour and a manuscript was rapidly re-written!
The pace of fetal physiology seemed to be very rapid in those days, even if each experi-
ment took a long time to complete. It’s just that there were many experiments going on
simultaneously and one or two were reaching completion.
(Letter from JSR to LDL, 17 April 2009)

In commenting upon some aspects of this work, Dawes reflected, “I set out to
speak about revolutions and cyclical rhythms in prenatal life. There certainly has
been a revolution in thought in the recognition that the physiological systems of the
fetus are exercised, though discontinuously. It will now be interesting to try to
design experiments to determine whether this activity serves a useful function in
development, as seems likely” (Dawes 1973, p. 970). Almost a decade later, Dawes
remarked, “… progress since 1970 has been swift. The broad outlines of physiologi-
cal control … is understood, but not by any means the details of all the mechanisms
involved. It has proved more complex than at first supposed. Smaller may be more
beautiful2, but evidently not simpler” (Dawes 1980, p.5).
In another reflection regarding his investigations of fetal breathing movements,
he stated,
These studies have developed logically and irrevocably, from the observation of episodic
fetal breathing arrested by a mild degree of isocapnic hypoxia. The contrast with control
mechanisms in the adult was obvious. I had hoped, even expected, that physiologic controls
in the fetus would be built on a simpler plan than in the adult. With the passage of years
I have learnt the hard way that it is not so. The fetus is very complicated, and the mecha-
nisms by which its physiologic functions are integrated, to use BARCROFT’s phrase, are
still a profitable subject of enquiry.
(Dawes 1985, p. 29)

Dawes’ son, Nicholas William has written regarding the rediscovery of fetal
breathing.
Pa recorded a … scan of [my son] Simon Dawes in utero, the first healthy human baby
control during the discovery of fetal breathing in Oxford. This … was taken on 27 March
1974 when Simon was 14 weeks gestation. [My wife] Sue Dawes … then gave birth to
Simon on 21 September 1974 … Geoffrey’s grandson, is now a doctor and team leader of
hospitalists at the Peter Lougheed Centre in Calgary [Alberta, Canada].
(Letter from NWD to LDL, 18 January 2009)

2
This is reference to Ernst Schumacher’s book, Small is beautiful (1973).
402 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

18.3 Early History of Fetal Heart Rate Monitoring

The fourth movement of Dawes scientific quadrivium was that of electronic fetal
heart rate (FHR) analysis. Following invention of the stethoscope in the early nine-
teenth century by the French physician René Theophile Hyacinthe Laennec (1791–
1826) (Laennec 1819), several workers used abdominal auscultation of the fetal
heart rate (FHR) to diagnose fetal well-being (Kergaradec 1822; Pinkerton 1969).
Although this is not the place to review in extenso auscultation and/or electronic
monitoring of the fetal heart, several aspects are of relevance. In his Observations
on obstetric auscultation… Evory Kennedy (1806–1886) of the Rotunda Hospital,
Dublin, was one of the first to recognize that abnormal fetal heart rate was a sign of
compromised fetal well-being with impending death of the fetus in utero. He
described auscultation with the stethoscope to aid in the diagnosis of “evidences of
pregnancy.” After noting its normal rate of “about 130 or 140 [beats] in the minute,”
Kennedy recorded the variation in fetal heart rate, “becoming suddenly more or less
frequent, and then returning to its natural state without any apparent reason…. The
external cause, which we shall find most frequently… is uterine action, particularly
when long continued, as in labour” (Kennedy 1833, pp. 90–91). He also noted the
effect of compression of the fetal head or “funis” (umbilical cord) on heart rate
decelerations, and recorded an instance of fetal death following deep deterioration
with disappearance of its heart rate (Kennedy 1833, pp. 92–93). Kennedy stressed
the value of mediate auscultation in the diagnosis of twin pregnancy and the fetal
positions, location of the placental soufflé, and as an aid to distinguish true from
pseudo-pregnancy. Kennedy concluded this tract by considering both the advan-
tages and difficulties of auscultation, stating “We would merely beg, that those who
have an opportunity, will give it a fair and impartial trial. As to the result we feel
perfectly satisfied. And in conclusion, … if its application be properly understood,
it will afford us as satisfactory and unerring signs, as any diagnostic means relied on
in medical practice” (Kennedy 1833, p. 260). In an Appendix, Kennedy considered
legal issues such as ascertaining the presence of pregnancy in the case of a woman
“convicted of a capital felony,” who pleads for a stay in execution because she “is
quick with child” (Kennedy 1833, p. 261ff; see Pinkerton 1969, 1984). Goodlin has
reviewed the contributions of other workers who auscultated the fetal heart rate, and
some aspects of its variation, during the latter-nineteenth and early-twentieth centu-
ries (Goodlin 1979).
Early in the twentieth century, an electrocardiogram of the human fetus first was
obtained (Cremer 1906); however, as noted earlier, continuous intrapartum elec-
tronic fetal heart rate monitoring as an alternative to traditional auscultation was not
introduced clinically until shortly after mid-century (Hon 1958, 1959, 1960; Larks
1961). In several reports, Edward Harry Gee Hon (1917–2006) (Fig. 18.2b) who
had a background in electronics (Yeo 2000) and “Ted” Quilligan, of Yale University,
described changes in electronic fetal heart rate monitoring (EFM) baseline variabil-
ity, and the patterns of bradycardia in association with uterine contractions (Hon
and Quilligan 1967, 1968). In particular they attempted to quantify FHR patterns of
18.3 Early History of Fetal Heart Rate Monitoring 403

bradycardia in response to uterine contractions on a rigorous basis, viz “early decel-

eration” being associated with head compression, “late deceleration” being associ-
ated with uteroplacental insufficiency, and “variable deceleration” being associated
with umbilical cord compression (Hon 1968; Hon and Quilligan 1967, 1968).
During the 1970s and 1980s, with the use of fetal scalp or other internal electrodes,
this technology became widely used, a practice of care that has continued to the
present. The attraction of this well-intentioned modality was the perception of many
that, by continuous recording and with supposed “objectivity”, fetal monitoring
with detection of bradycardia would provide almost immediate evidence of intra-
partum hypoxia. In turn, this would permit the attending physician to intervene,
thereby avoiding the severe acidosis and/or asphyxia that could eventuate in atten-
dant sequelae (Hammacher 1962, 1966, 1967; Kubli et al. 1969) including respira-
tory distress syndrome (Hon et al. 1975). In one of the early studies on high risk
patients at the Los Angeles County General Hospital, Hon, Quilligan, and col-
leagues reported on a number of aspects of fetal heart rate monitoring. In consid-
eration of the particular benefits of electronic FHR monitoring in the premature
infants in the 1,000–1,500 g weight range; they admitted that a well-controlled
trial with long-term infant growth and development studies was required (Paul and
Hon 1974).
In turn, Roberto Caldeyro-Barcia (1921–1996) (Fig. 18.2c) of the University of
Uruguay, Montevideo, another pioneer in electronic fetal heart rate monitoring,
referred to the first two of these patterns of bradycardia as “type I” and “type II
dips”, respectively (Caldeyro-Barcia et al. 1966; Schwarcz et al. 1974). These latter
workers also studied aspects of the fetal electrocardiogram tracing in detail
(Figueroa-Longo et al. 1966). Later, Caldeyro-Barcia wrote an account of the evalu-
ation of his thinking in regards to EFM patterns in human labor, their relation to
uterine activity, and to simultaneous blood gas measurements from the fetus
(Caldeyro-Barcia 1985). In this essay he described some aspects of a meeting he
organized devoted to the topic “Effects of labor on the fetus and newborn” in
Montevideo in October 1964. Here, Hon, James, Quilligan, Saling, and others par-
ticipated in a joint study (Fig. 18.2b). Caldeyro-Barcia recorded that after the meet-
ing, the group worked together to monitor the fetuses of three patients in labor,
recording electronic FHR, uterine contractions, and sampling fetal scalp blood. This
was the first time these methods had been used simultaneously (Caldeyro-Barcia
1973, 1985).
With the use of microballoons, Caldeyro-Barcia and colleagues also were the
first to record intramyometrial pressures of pregnant women in labor. By placing
these in different parts of the uterus, they studied the origin and characteristics of
pacemaker areas with spread of the wave throughout the organ (Méndez-Bauer
et al. 1961). In an attempt to objectify the regularity of uterine contractions, in early
reports these workers measured the “coefficient of variation” of the contraction
peak-to-peak intervals, as determined from amniotic fluid pressure, and then calcu-
lated the “index of uterine arrhythmia”. They then applied this index as a measure
of uterine efficiency in cases of uterine inertia and in response to drugs, distinguish-
ing between true and false labor (Effer et al. 1969). In further studies, in which they
404 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

defined uterine activity as the product of contractile intensity multiplied by fre-

quency (e.g., mmHg per 10 min, or “Montevideo Unit”), Caldeyro-Barcia and col-
leagues determined that in normal labor near-term, uterine activity ranged from 100
to 250 Montevideo Units (Krapohl et al. 1970). As noted earlier, these workers also
used this methodology to measure hydrostatic pressures in the placental intervillous
space of the rhesus monkey (Reynolds et al. 1968).
Despite efforts to objectify rigorously the fetal electrocardiographic tracings,
some have argued that, for the most part, this analysis has remained relatively sub-
jective (Goodlin 1977, 1979; Wulf 1985). A number of noncontrolled, retrospective
analyses supported the view that continuous monitoring would allow the caregiver
to detect fetal hypoxia and/or acidemia, although this resulted in significantly
increased rates of cesarean section. As noted earlier, in North America in addition
to continuous EFM monitoring per se, clinicians challenged the fetal heart rate
response by inducing uterine contractions (contraction stress test, CST or oxytocin
challenge test, OCT) (Pose and Escarcena 1967; Ray et al. 1972). As exemplified in
the work of Dawes and his group, others emphasized the importance of FHR vari-
ability. This foreshadowed introduction of the relatively popular non-stress test
(NST), a “reactive” test being characterized by two accelerations (of 15 beats per
min minimum amplitude lasting for a minimum of 15 s) within 10 min (Lee et al.
1975, 1976; Nochimson et al. 1978; Schifrin et al. 1979; Trierweiler et al. 1976).
A problem with these tests were their relatively high rate of false positive (e.g., not
truly abnormal) results (Parer 1991).
In large part because of the fear of adverse fetal outcome during the course of
labor, electronic fetal heart rate monitoring has achieved near universal acceptance.
Nonetheless, two large prospective, randomized trials in high-risk pregnancies at
the University of Colorado failed to demonstrate the hoped for benefits in infant
outcomes (Apgar scores, umbilical venous or arterial blood gases, neonatal morbid-
ity or mortality) (Haverkamp et al. 1976, 1979). A later comparative study by this
group, in which the infants later were assessed at 9 months of age, showed no sig-
nificant differences in growth, development, Bayley Scales of Infant Development,
or Milani Comparetti tests (Langendoerfer et al. 1980). In yet another follow-up at
18 months of age, no significant differences were seen in psychomotor-development
scores, and the incidence of cerebral palsy was slightly greater (but not signifi-
cantly) in the electronically monitored group (Shy et al. 1990). Not all authors have
agreed, however. In at least two large studies with ultrasound measurement of the
fetal risk assessment by the “biophysical profile” (see above; breathing movements,
gross body movements, muscular tone, reactive heart rate (acceleration associated
with body movements) and amniotic fluid volume; Manning et al. 1980; Platt et al.
1983), considering both short- and long-term indices of fetal condition, with FHR
monitoring the corrected perinatal mortality rate was reported to be decreased sig-
nificantly (Manning et al. 1985, 1993; Platt et al. 1983). Frank Arthur Manning, at
the Albert Einstein College of Medicine in the Bronx, has reviewed the clinical
value of the biophysical profile and its scoring in the prediction and prevention of
perinatal morbidity and mortality (Manning 1999).
18.4 Subsequent Studies on Electronic Fetal Heart Rate Monitoring 405

18.4 Subsequent Studies on Electronic Fetal Heart

Rate Monitoring

In the majority of Geoffrey Dawes’ studies of fetal breathing activity, he also had
recorded the fetal heart rate. Soon, he came to appreciate the limitations and frailties
of visual assessment of the electrocardiographic tracings obtained, and, following
the introduction of personal computers commenced to use this new digital technol-
ogy to analyze the mass of data collected. In addition, although not widely quoted,
it is clear that a critical review of fetal monitoring by Robert Goodlin, then of the
University of California Davis (Goodlin 1979) influenced other workers in the field.
Dawes probably was one of these. Thus, beginning in the late 1970s through the
1980s and until the end of his life, Dawes with colleagues worked to measure heart
rate variability in a more objective and quantitative manner. To this end, they
employed the power of numerical analysis, including fast Fourier power spectral
analysis, to study heart rate, its variability, and the implications of changes as an
index of well-being. In an early, highly cited study in fetal sheep, the Dawes’ group
demonstrated several rhythms in short-term variability, which increased as the fetus
matured beyond 130 dpc, and also increased in response to hypoxia, despite the
concomitant arrest of breathing movements (Dalton et al. 1977). With neuromuscu-
lar blockade by gallamine to abolish breathing movements, the heart rate variability
was significantly reduced (Dalton et al. 1977). (It must be noted, however, that gal-
lamine also has a vagolytic action.) In humans, the Dawes group confirmed this
increase in FHR variability with gestational age, showing that during the last trimes-
ter, it was not the presence of accelerations, nor the absence of decelerations, nor
overall variability per se that best reflected fetal state, but rather the presence of
intermittent episodes of both high and low variability (Dawes et al. 1982a, b). In
lambs, Dawes and colleagues demonstrated an attenuated relation of baroreceptor
sensitivity and activity (by relation of FHR to arterial blood pressure) to heart rate
variability in both fetus and newborn, as compared to adult, and demonstrated that
this variability was not associated with changes in ECoG state (Dawes et al. 1980).
In a related report, in response to physiologic changes in humans, the beat-to-beat
variations were shown to alter in a complex manner, independent of either breathing
or body movements (Dawes et al. 1981a).
With the obstetrician–gynecologist Christopher Willard Redman of Oxford, with
whom he was to collaborate during the remainder of his career, Dawes worked to
develop further reliable methods to assess heart rate and its variability as indices of
fetal well being in the human. In the first of their collaborative studies, they devel-
oped an algorithm to quantify record quality (signal-to-noise ratio) to correct for
signal error loss, which could be excessive during episodes of high heart period
variability. They then used this approach to explore the effect of fetal body move-
ments and breathing on FHR variability, and establish the value of these measures
as an index of fetal well being (Dawes et al. 1981b). By simultaneous measure-
ments of FHR variability with use of both direct EFM and ultrasound, during the
latter half of gestation in humans, they showed a reasonable correlation of these
406 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

methods, with a lower percent failure time of Doppler ultrasound after 28 weeks
gestation, compared to the prior 12 weeks. In this study, they also determined nor-
mal variations in pulse interval averaged over 4 s epochs, demonstrating that an
accurate measure of accelerations and decelerations could be obtained from the
ultrasound records (Dawes et al. 1981b). Because it was believed that administra-
tion of the opiate-like agonist pethidine (Demerol) to women in labor resulted in
loss of FHR variability, Dawes assessed this effect, showing that although FHR
accelerations of >10 beats per min were reduced significantly (46 %), the reduction
in overall variability was only 20 % (Wheble et al. 1988). By use of a microproces-
sor at the patient’s bedside, Dawes and colleagues attempted to determine the extent
to which fetal compromise by asphyxia might be diagnosed on the basis of reduced-
heart rate variability to warn of impending death. Following a decade of studies, in
1989 a commercial instrument (System 8000) was developed, for use by clinicians
to measure accurately FHR and its variation as well as fetal movements (Dawes
et al. 1991b; Dawes and Redman 1993). For this innovation, in 1990 Dawes received
the British Design Award. Ms. Sue Halson-Brown, who worked for Oxford Sonicade
Ltd., and who collaborated with Dawes and colleagues in developing the System
8000, recounts that she became close friends with Geoffrey and his wife Margaret,
often enjoying afternoon tea in their garden. Further she noted that the British
Design Award was given “… for technical innovation in an emerging field”, and the
ceremony was followed by “… a marvelous lunch at the Savoy” (SHB letter of
LDL, 13 December 2011).
Dawes’ studies demonstrated that heart rate variability was a more reliable mea-
sure of fetal deterioration than decelerations per se, or the velocity of umbilical
artery waveforms determined by ultrasonography (Dawes et al. 1992a, b). These
workers also showed variability to be reduced in instances of severe anemia as a
consequence of rhesus alloimmunization (Economides et al. 1992). In addition,
they presented evidence that, compared to mean epoch-to-epoch variation in the
normal near-term fetus of 50 ms and <20 ms in cases of chronic hypoxia, that below
3 ms was associated with metabolic acidosis and risk of intrauterine death
(Street et al. 1991). Dawes also demonstrated the requirement for 1 ms accuracy of
beat-to-beat measurements, if short-term variability, and thus the state of fetal well
being, was to be assessed reliably (Dawes 1993). Dawes and his colleagues also
demonstrated a significant increase in short-term FHR variability following dexa-
methasone administration (Dawes et al. 1994). They also stated that the normal
range of basal FHR to equal 120–160 beats per min (Dawes et al. 1996). Dawes
with Redman and others continued to fine tune this methodology throughout the
remainder of their careers (Dalton et al. 1983; Dawes et al. 1981a, b, 1985, 1990a, b,
1991a, b, 1993, 1996; Dawes and Redman 1987, 1992, 1993; Henson et al. 1983,
1984; Lawson et al. 1982, 1983, 1984; Pello et al. 1991; Smith et al. 1987, 1988;
Spencer et al. 1987; Visser et al. 1982).
While Dawes appreciated that heart rate analysis was of great value for antepar-
tum assessment of fetal well-being, he had hoped that it also would be of value in
intrapartum assessment. Unfortunately, at that time, that was not to be the case. An
analysis of the FHR tracings of 394 women in labor at or near term, disclosed a wide
18.5 Some Contemporary Developments 407

range of heart rate with diversity of patterns. In addition, epidural anesthesia was
identified as a confounding variable that affected FHR patterns (higher heart rate
with less variation), despite having no apparent influence on the infant at birth
(Pello et al. 1991). In his last published paper, with his son Nicholas, a D.Phil.
physicist–computer scientist, Dawes reported significantly greater heart rates in
female than male fetuses during labor (but not prior to the onset of labor), a differ-
ence exaggerated by epidural anesthesia. In view of this finding, he stressed the
requirement to consider the multiple variables in this regard (Dawes et al. 1999).
“Mont” Liggins has given some insights into the controversy this approach initially
engendered, especially the requirement to measure with great accuracy the fetal
heart beat-to-beat interval (Liggins 1998, pp. 117–118). Others have expressed their
skepticism as to the fundamental value of these particular studies by the Nuffield
group, stating that this latter decade and more of Dawes’ life occupied by this work
were “wasted years” (Several Personal Communications to LDL).

18.5 Some Contemporary Developments

As is widely appreciated, many hold that the presence of asphyxia is a major cause
of intrauterine death or hypoxic ischemic encephalopathy with impaired neurologi-
cal and cognitive development in survivors (Low 2004; MacDonald 1996). In view
of this belief, a number of investigators have sought to discover the Holy Grail of a
diagnostic tool to diagnose fetal asphyxia accurately. The variation of the fetal heart
rate appeared to offer a possibility in this regard, as FHR variability was believed by
many to be of value in determining the state of fetal well being and impending
asphyxia. In the years during and following Dawes’ studies, a number of individuals
have contributed to this field.
Perhaps surprisingly, it was not until the mid to late-1970s that randomized con-
trolled trials of electronic FHR monitoring first appeared. These failed to demon-
strate dramatic benefits (Thacker et al. 2006). In 1996, a Task Force of the European
Society of Cardiology and the North American Society of Pacing Electrophysiology
reviewed the value of heart rate variability in healthy adults as well as those with vari-
ous cardiovascular and non-cardiovascular disorders. The analysis included aspects
of heart rate variability, and the relation to function of the autonomic nervous system,
including sympathetic and parasympathetic outflow, physiologic phenomena such as
respiratory activity, and other functions. This report concluded that considerable cau-
tion was required in the interpretation of variables such as heart rate variability, the
electrocardiographic R-R interval, and other functions (Task Force … 1996).
Nonetheless, in the obstetrical literature mounting evidence suggested a strong cor-
relation between prolonged hypoxia and/or asphyxia, and loss of baseline variability,
bradycardia or other abnormal FHR patterns, with subsequent neurological damage
(Parer 1988, 2003; Siira et al. 2005), and further the association of non-reassuring
FHR patterns and intrapartum stillbirth (Parer 1979). Thus, because of the nonspeci-
ficity of FHR decelerations per se, intraobserver and interobserver variations, and
408 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

other methodologic variables, the recognition of FHR variability with non-reassuring

patterns came to be of critical importance. Stressed by many was the absence of
objective, observer-independent measures of the association of FHR variability to
asphyxia. For instance, a NICHD research planning workshop included participation
of a dozen and a half of the leaders of the field. They could reach no consensus of
agreement on guidelines of management, other than to stress that a “normal” FHR
tracing showed normal baseline rate, moderate variability, with the presence of accel-
erations and absence of decelerations (Parer and Quilligan 1997). More recent
reviews have endorsed this assessment (Malcus 2004; Parer 2003). In 2001, the
Royal College of Obstetricians and Gynaecologists published “… Evidenced-based
… guidelines” on the use of electronic FHR monitoring that included a review of the
literature on the topic, and recommended fetal blood sampling in instances of two or
more abnormalities in heart rate (Royal College of Obstetricians and Gynaecologists
2001). As an aside, although fetal pulse oximetry, and its correlation with both elec-
tronic FHR and intrauterine pressure measurements have gained some popularity in
Europe, this has not been the case for the USA; and an NICHD-supported clinical
trial showed that this failed to reduce cesarean section rates (Bloom et al. 2006).
In a 2003 survey of electronic fetal heart rate monitoring, Julian Thomas “Bill”
Parer of the University of California San Francisco, concluded,
… to justify our continued use of EFM, we need to clean up our house. We must come to
some agreement on a national level about interpretation and management. We must teach
EFM more appropriately. We must carry out surveys to determine accurately the relation-
ship between FHR patterns and newborn academia. We must define the realities of logistics
involved in emergent intervention so that hospitals with less comprehensive facilities can
continue to serve their local communities without fear of legal vulnerability. Only then can
this potentially valuable screening test for newborn acidemia be appropriately evaluated,
and then either be discarded if results are negative for efficiency or accepted with an aura of
scientific decency if results are positive.
(Parer 2003, pp. 562–563)

In further consideration of the guidelines promoted by several groups, Parer

observed that “… we have found them to be of limited use” (Parer and Ikeda 2007).
In 2008, in partnership with the American College of Obstetricians and Gynecologists
(ACOG) and the Society for Maternal–Fetal Medicine, the NICHD convened
another workshop to reassess and update the 1997 definitions and guidelines, and to
standardize the terminology and interpretations employed by various workers. The
participants adapted a three-tier category classification: viz I, normal tracing with
moderate baseline variability; II, intermediate, non-classifical; III, abnormal tracing
with bradycardia, absent variability, and sinusoidal pattern. They also reaffirmed
that a tracing is a poor predictor of those infants that will develop long-term neuro-
logical sequelae (Macones et al. 2008). The following year, a Practice Bulletin of
ACOG reassessed the definitions of EFM pattern categorization and reviewed clas-
sification systems (ACOG 2009). Although recommending electronic monitoring in
instances of high risk pregnancy, and continued use of the three-tiered system of
categorization, the committee acknowledged a number of deficiencies including
problematic tracings without additional data and poor interobserver and intraobserver
reliability (ACOG 2009).
18.5 Some Contemporary Developments 409

Because the intermediate (tier II) category consists of a heterogenous array of

patterns with variations in baseline fetal heart rate, variability, and decelerations, an
interdisciplinary group from Canada and the USA has developed specialized soft-
ware to analyze and categorize EFM traces, with a five-tier color coded classifica-
tion to aid in the interpretation of tracings and to be predictive of adverse outcomes.
They present a high correlation of their predictability with outcome (Elliott et al.
2010; Parer and King 2010). In a test of the correlation of interpretation of abnormal
FHR tracings by use of the five-tier color-coded framework with that of PeriCALM
computer analysis, five expert perinatologists achieved remarkable agreement both
on the FHR tracing itself (89 % within one tier) and with that of the computer (Parer
and Hamilton 2010). A metaanalysis of 12 randomized, controlled, clinical trials
suggested the chief significant benefit of FHR monitoring to be a reduction of neo-
natal seizures (Thacker et al. 1995), and several reports reaffirm the validity of FHR
variability as an appropriate index of asphyxia (Frasch et al. 2009), and lowered
infant mortality (Chen et al. 2011). Nonetheless, some skepticism has continued
regarding evidence for the effectiveness of routine EFM, its role in minimizing the
occurrence of hypoxic ischemic encephalopathy and concerns as to its costs, as
opposed to its benefits (Banta and Thacker 1979a, b, 2001; Goodlin 1977; Shy et al.
1990; Thacker et al. 1995). A contemporary report suggests that internal tocodyna-
mometry during either induced or oxytocin-augmented labor, demonstrates no
advantage over that of external monitoring in FHR pattern recognition or neonatal
outcome (Bakker et al. 2010).
A retrospective cohort study of 2004 singleton births and infant mortality in the
USA (1,732,211 live births in the study population, 42 % of the total), among which
89 % were monitored electronically, reported significant reductions in low Apgar
scores, neonatal mortality, and incidence of neonatal seizures. In turn, the rates for
operative deliveries increased (Chen et al. 2011). As noted by others, problems
remain in the interpretation of FHR patterns and the assessment of fetal well-being.
These include: the use of Apgar scores and/or neonatal seizures as surrogate mark-
ers for hypoxic ischemic induced neurologic injury, and other caveats as noted
above (Devoe 2011b).
Based on observation that a biphasic or depressed electrocardiographic
ST-segment usually was associated with fetal hypoxia, during the 1980s structured
ST-waveform analysis (STAN) was developed. This methodology included
improved signal processing, computerized calculations of several electrocardio-
graphic variables (T:QRS ratio, ST-segment depression), and clinical guidelines for
applying this information for patient management (Rosén and Lindecrantz 1989).
From the Universities of Lund and Gothenburg, Sweden (Amer-Wåhlin et al. 2001),
a 2001 randomized trial of 4,966 near-term women in labor, demonstrated that
STAN combined with cardiotocography resulted in significantly lower rates of
umbilical arterial acidosis and operative delivery for fetal distress, as compared to
cardiotocography alone (Amer-Wåhlin et al. 2002). On the basis of another multi-
center trial, the sensitivity and specificity of this analysis for fetal hypoxia and aca-
demia were soon established in Scandinavia (Arulkumaran et al. 1990). In the USA,
a non-randomized cohort study established the agreement for clinical management
410 18 Fetal “Breathing” in the 1970s, and Fetal Heart Rate Analysis…

between clinician–users and STAN experts (Devoe et al. 2006). With the use of this
technique, a decision tree model has predicted a significant reduction in the occur-
rence of cerebral palsy with increase quality of life and lifetime cost savings (Heintz
et al. 2008). In 2005, the US Food and Drug Administration’s Obstetrics and
Gynecology Advisory Panel voted to approve the STAN® fetal heart rate monitor to
assist clinicians to identify infants at risk (http://www.obgyn.net/print.asp). A more
recent Swedish prospective clinical study on the use of STAN, conducted over 7
years in almost 13,000 term pregnancies, demonstrated a major reduction in fetal
metabolic acidosis, increase in neonatal outcome, with a stable rate of vaginal deliv-
ery (Norén and Carlsson 2010).
Lawrence Daniel Devoe of the Medical College of Georgia has placed many of
these relatively recent developments in perspective (Devoe 2011a). This review
notes that, while STAN has been used successfully in Europe and has largely
achieved some of the goals initially promised by EFM to reduce perinatal morbid-
ity and unneeded operative interventions, similar outcomes have yet to be demon-
strated in the USA. To this end, the NICHD has charged the Maternal–Fetal
Medicine Unit network to undertake a prospective randomized controlled trial of
STAN. This study, now underway at a number of network centers, aims at showing
that US clinicians, trained in the use of the STAN system can achieve clinical out-
comes comparable to those of the original Swedish randomized trial. It is antici-
pated that this trial will be concluded in the next several years. In terms of
technologic innovations, a new monitoring system, the Monica AN 24, has been
developed that utilizes advanced signal processing to derive fetal heart rate signals
from fetal ECG and maternal uterine activity from electrohysterography obtained
via transabdominal transducers for prolonged periods of time (Graatsma et al.
2009; Jacod et al. 2010). This system, currently being marketed in the USA, in
addition to using wireless transmission, is purported to have improved signal cap-
ture in obese patients. Large prospective clinical trials are still awaited to determine
whether the Monica AN 24 will result in improved outcomes with decreased mor-
bidity and mortality when compared to standard external monitors. Finally, through
the use of smart phones or tablets, applications are being developed to bring EFM
recordings with their corresponding patient data to the obstetrician, regardless of
location. The purported advantage of data immediacy is intriguing and eliminates
the problem of bedside staff’s communicating a visual pattern verbally to a distant
provider. As yet, we await the results of trials demonstrating such improved patient
care and outcome.

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Chapter 19
Dawes’ Contributions to Symposia
and a Summing Up

In addition to his scientific contributions per se, and helping to inspire the small
army of leaders-to-be that came of age under his tutelage, Geoffrey Dawes had a
special and amazing gift for synthesizing information and ideas. Many of his over-
views of various issues were given as invited lectures, keynote addresses, and intro-
ductions to various Proceedings and Conferences. For instance, in what was to be
the first of several symposia devoted to the “baffling problem” of sudden infant
death syndrome (SIDS), held in 1963 in Seattle, WA (Wedgwood and Benditt 1965),
with his background in physiology and pharmacology, Dawes brought valuable
insights to the discussion. In his presentation on cardiovascular pulmonary reflexes,
he emphasized the relation of his studies with asphyxia in newborn and young
lambs to the enigma of SIDS. Additionally, in terms of casual mechanisms, he
stressed the necessity to consider alternative hypotheses (Dawes 1965). A decade
later at a Bethesda, MD Symposium devoted to this topic (Bosma and Showacre
1975), Dawes participated in the discussion of almost half of the formal presenta-
tions. In concluding comments, he challenged the participants on their many
assumptions, and the supposed “facts” presented; “I would be careful about this
evidence,” he cautioned (Dawes 1975, p. 266). Importantly, Dawes formulated a
number of ideas relating to SIDS, and outlined research questions that required
exploration (Dawes 1975). Many of these remain unanswered to the present day
(Kinney and Thach 2009).

19.1 Ciba Foundation Symposia

A particular contribution to fetal and neonatal physiology in which Dawes played a

key role, was the series of Symposia sponsored by the Ciba Foundation. Table 19.1
lists these symposia, in which Dawes participated or organized. Following World
War II, in 1949 Ciba Ltd. (currently Novartis) of Basel, Switzerland established a
Foundation in London to promote international cooperation in medical and

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 421
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_19, © American Physiological Society 2013
422 19 Dawes’ Contributions to Symposia and a Summing Up

Table 19.1 Ciba Foundation and other symposia on fetal-neonatal development

Year/title Editors Chairman Participants Presentations Pages
1961/Somatic Stability Wolstenholme Robert 30 20 393
in the Newly Born and O’Connor Alexander
McCance
(1898–
1993)
1967/Development of De Reuck and P. Hugh-Jones 25 20 408
the Lung Porter
1969/Foetal Autonomy Wolstenholme Geoffrey 25 16 326
and O’Connor Sharman
Dawes
1974/Size at Birth Elliott and Knight Geoffrey 27 15 408
Sharman
Dawes
1977/The Fetus and Knight and Geoffrey 26 18 481
Birth O’Connor Sharman
Dawes
1981/The Fetus and Elliott and Geoffrey 25 15 372
Independent Life Whelan Sharman
Dawes
1985/The Roots of Rooth and Rooth and 15 17 132
Perinatal Medicine Saugstad Saugstad
1990/Fetal Autonomy Dawes, Borruto, Geoffrey 17 14 186
and Adaptation Zacutti and Sharman
Zacutti Jr. Dawes

chemical research. Its first (and for three decades) director was Sir Gordon
Wolstenholme (1913–2004). These Symposia, each held on a topic of general inter-
est to medicine and biomedical science, were held at its headquarters, Ciba House,
41 Portland Place, London. Recognizing the barriers that exist between biomedical
scientists and healthcare specialists, the goal of these was to be “…not a laboratory
for mixing compounds, but a laboratory for mixing scientists” (Wright 2004). The
Foundation’s motto Consocient gentes [let the people come together] exemplified
this objective. Sir George White Pickering (1904–1980) has detailed several aspects
of the Ciba Foundation series of symposia. He noted that perhaps the most impor-
tant contribution of these Conferences has been the discussions that followed each
presentation, “…which often begins lifelong friendships between scientists who
have met for the first time” (Pickering 1979, p. 98). The first of a half-dozen Ciba
Symposia devoted to the developing organism, considered the topic Somatic
Stability in the Newly Born. Thirty scientists from various disciplines gathered
under the chairmanship of Robert A. McCance, to consider the lung and its develop-
ment, numerous aspects of fetal and newborn metabolism, thermogenesis, and the
issue of homeostasis. Dawes presented his most recent work on oxygen consump-
tion and hypoxia in the newborn lamb. In the concluding papers, Clement Smith of
19.1 Ciba Foundation Symposia 423

Harvard Medical School and Sir John Hammond (1889–1964) of Cambridge

University considered the human clinical and veterinary implications, respectively,
of these topics (Wolstenholme and O’Connor 1961). Several years later in 1967,
under the chairmanship of Philip Hugh-Jones (1917–2010) of King’s College
Hospital Medical School, the Ciba Foundation Symposium was devoted to
Development of the Lung (De Reuck and Porter 1967). At this conference,
consideration was given to the phylogeny and ontogeny of lung development, the
physiology and biophysics of the pulmonary gas/liquid interface, respiratory gas
exchange in the fetus, and initiation of breathing in the newborn. Again, Dawes
reviewed his work and that of others on oxygen consumption of the developing fetus
and placenta, and contributed to the discussion of essentially every presentation,
asking probing questions and challenging assumptions (Dawes 1967).
Several of these Symposia followed the discovery in sheep that the fetal adrenal
glands play a key role in determining the onset of parturition. No doubt because of
the vigorous role he played in contributing to previous Symposia, Dawes was asked
to organize and chair the Symposium Foetal Autonomy (Wolstenholme and
O’Connor 1969). Again, two dozen investigators from around the world considered
issues of implantation and the maternal recognition of pregnancy, the fetus as an
allograph, fetal endocrine autonomy, fetal metabolism, circulation, and neuromus-
cular function, the role of the fetus in the initiation of parturition, and so forth. In his
introduction to the gathering, Dawes stressed the importance of fetal homeostasis,
e.g., that despite the embryo/fetus passing through a number of critical transitions,
“…at implantation, during organogenesis, at the time of imprinting the sexual char-
acter on the nervous system, at birth, and after birth during the establishment of
behavioral patterns—periods which pass never to return. Failure to make the transi-
tion at the right time is crippling or lethal.” Further, he called attention to the para-
dox that, despite their exploring several aspects of fetal biology, to a great extent the
attendees were separated by both discipline and geographical distance, and they
published in the journals of different learned societies, probably not read by one
another. He noted, “There…remains a large, almost unexplored territory between
the embryologist and the foetal physiologist. The gap between the experimental
immunologist and the obstetrician or paediatrician is only slightly less.” Dawes
stressed the joint goal, to explore important gaps in knowledge, and to bridge
connections between the many different branches of the subject (Dawes 1969b, p. 1).
In his main address at this Symposium, Dawes reviewed the topic “Foetal blood gas
homeostasis,” emphasizing its stability being dependent upon proper circulatory
regulation. Drawing upon his background in pharmacology, he reviewed his and
others’ work on the role of the systemic arterial chemoreceptors in this regulation.
He called attention to the fact that, beginning at 0.6–0.7 gestation (85–100 dpc)
onwards, fetal sheep show evidence of central nervous system regulation of the
circulation with this playing a key role in its blood gas homeostasis. Additionally,
he noted that although section of the carotid nerves (from the carotid body and
sinus) had little effect on fetal responses to hypoxia, section of the cervical vagus or
aortic nerves resulted in vasodilatation with blood pressure decrease, and abolition
of the hypoxia-induced rise in blood pressure (Dawes 1969b). At the conclusion of
424 19 Dawes’ Contributions to Symposia and a Summing Up

this symposium, Dawes reminded his colleagues of the apparent paradox of the
developing fetus that, despite its immaturity, many aspects of its cellular and organ
system functions were quite adequate and appropriate, raising the question, by what
criteria should one define “…immaturity in different organ systems?” He continued
with the challenge to gain an understanding of details of systems the group had not
addressed, such as immunological competence, mineral metabolism, and enzyme
development. Dawes concluded, “…the present solution to the problem of mam-
malian viviparity is not merely compatible with but is directly dependent on a high
degree of foetal autonomy” (Dawes 1969a, pp. 315–316).
For the 1974 Ciba Foundation Symposium, Size at Birth, again over two dozen
investigators considered issues such as: what factors determine the size of a new-
born mammal? What consequences follow being born either abnormally small or
much too large? How does one diagnose accurately the genesis of variations in size?
What are the possibilities of correcting abnormal growth rates? To what extent can
postnatal compensatory measures prevent deficits in ultimate intellectual and physi-
cal development in the severely intrauterine growth retarded infant? In his introduc-
tion to this volume, as he had at earlier symposia, Dawes emphasized the critical
role antenatal influences play in development and life of the newborn. Asking,
“what are our long-term objectives?”, Dawes stressed not only the ability to diag-
nose variations and abnormalities in the size of the fetus, but the biologic basis for
it being either “…to large or too small, …and to discover whether [such aberrations
could] be prevented, and whether [they] can be cured…” (Dawes 1974, p. 1). Again,
in the discussions that followed each of the over a dozen presentations, Dawes stim-
ulated the dialogue and posed challenging questions (Elliott and Knight 1974).
Several years later, a Ciba Foundation Symposium again considered issues
regarding the role of the fetus in the timing of its birth, The Fetus and Birth (Dawes
1977). The two dozen scientists from far and wide explored potential mechanisms
by which the fetus determined when it would be born. These included: the roles of
the fetal hypothalamic–pituitary–adrenal axis, estrogens and/or progesterone with-
drawal, prostaglandins, and the extent to which these differ among the several spe-
cies. As conference Chair, in his introduction, again Dawes posed questions to be
discussed with particular reference to the discoveries during the previous decade.
Importantly, he emphasized the critical necessity to attempt to resolve issues of
contention, and to probe more deeply into the cellular and biochemical pathways of
the mechanisms involved. For example, he challenged the concept that the fetal
control of the timing of parturition is explored to best advantage in ruminants as the
sheep or goat. He also raised a number of questions regarding the role of fetal adre-
nal steroids, that of prostaglandins, and the uterine and cervical responses to hor-
monal stimulation (Dawes 1977).
The last of the Ciba Foundation Symposium which Dawes would chair was that
of 1981 on The Fetus and Independent Life. Again, the two dozen scientists, includ-
ing many who participated in prior Symposia, dissected the maturation of various
organ systems of the fetus and the newborn infant. Topics included: development of
the hypothalamic–pituitary–adrenal axis, the placenta and its hormone production,
19.2 The Barcroft Centenary Symposium 425

fetal growth factors, metabolism, central nervous system transmitter systems, and
development of the lung. In addition to considering the central regulation of fetal
breathing movements, in his introduction Dawes reviewed a number of questions
regarding the ontogeny of various fetal systems, basic issues of fetal growth, and the
possible role of circadian rhythms. He challenged the participants,
This symposium is designed to follow a somewhat different path from those previously
organized by the Ciba Foundation that were directly related to the basic sciences of perina-
tal medicine… The range of disciplines of the participants is unusually wide. The purpose
is not just to rehearse recent advances in specialist aspects of the development of the mam-
malian fetus towards independence, but to identify and discuss large areas of research in
relation to the control of integrated physiological functions. Can we begin to see a coherent
pattern in the stages of fetal development? Is that pattern determined by the selection of
broad physiological mechanisms which serve an essential purpose in survival to birth and
independently thereafter? Or is it an accident of phylogeny?
(Dawes 1981, p. 3)

19.2 The Barcroft Centenary Symposium

In 1972, on the one hundredth anniversary of Sir Joseph Barcroft’s birth, Cambridge
University hosted a symposium, Foetal and Neonatal Physiology. Held at the
Physiological Laboratory, this was the first such large international gathering since
the Cold Spring Harbor Symposium held two decades earlier (Demerec 1954). The
Proceedings, edited by Kenneth W. Cross, included contributions from over 100
developmental physiologists and other scientists (Cross 1973).
In commenting later upon the Barcroft Symposium, Dawes attributed the
considerable increase in interest in the field to several factors. These included the fact
that the physiology of the fetus and newborn, “…was one of the few branches of
systems physiology in which major advances were being made” (Dawes 1984, p. 259).
As examples, he noted the discovery of pulmonary surfactant and the rapid recogni-
tion of its clinical significance in respiratory distress of the prematurely born infant
(see above). Dawes also noted the important recognition of “critical periods” as
being essential to normal development, citing the work of Hubel and Wiesel (noted
above). A second factor Dawes acknowledged for popularization of the study of
fetal and neonatal physiology, was that of technological advances such as the
chronic catheterization of the fetus (Meschia et al. 1965), which allowed measure-
ments of respiratory blood gases and pH, and various hormones and other biochem-
icals under physiologic, steady-state conditions. In conjunction with these advances
were those methods employed to produce fetal growth retardation experimentally in
a number of species (see Elliott and Knight 1974). Dawes advanced a third critical
factor, the appreciation by clinicians that knowledge of basic physiologic principles
often was required to affect appropriate interventional and/or therapeutic measures
of clinical problems in obstetrics and neonatal pediatrics. In addition to respiratory
distress syndrome in the premature newborn infant, examples included problems
426 19 Dawes’ Contributions to Symposia and a Summing Up

such as maintaining newborn body temperature, and maintaining the concentrations

of blood glucose and other metabolites. Dawes also emphasized the urgent need to
gain an understanding of the genesis of congenital malformations (Dawes 1984).
A decade later, in a satellite symposium Fetal Physiology and Behavior, held in
Melbourne, Australia, in conjunction with the 1983 International Union of
Physiological Sciences meeting, Dawes addressed the “changing direction” of fetal
physiology during the previous three decades. He credited the increased interest in
this field to the main factors to which he had referred previously: this was one of the
few branches of physiology in which major advances were being made at the sys-
tems level, important technical innovations allowed studies of many systems in the
unanaesthetized “physiologic” preparation, and clinical problems in perinatology
and neonatology demanded exploration of fundamental mechanisms and contribu-
tions to understanding. He concluded, detailing several differences between labora-
tory experimental animals and humans, stressing the challenge to understand these
differences at a deeper level (Dawes 1984). A decade later, Dawes rereviewed these
issues (Dawes 1994).

19.3 The “Dawes Symposium” and Others

In 1984, to honor Dawes for his four decades of inspiring young investigators to
excellence and other contributions to life, and prior to closure of the Nuffield Institute,
Colin T. Jones, of the Nuffield Institute, and Peter Nathanielsz, of Cornell University,
Ithaca, NY, organized a conference, The Physiological Development of the Fetus and
Newborn, held at St. Catherine’s College, Oxford (Jones and Nathanielsz 1985). As
a testimony to Dawes and his influence on the field, over 300 investigators, many of
whom had worked at the Nuffield Institute, gathered for 6 days to share their discov-
eries, and give “…tribute to the influence of Geoffrey Dawes and an inspiration to
convince present and future generations of the challenge that studies on development
provides” (Jones and Nathanielsz 1985, p. xix). In his closing essay, “Perinatal
Physiology, the Past, Present, and Future” Dawes reviewed a number of contribu-
tions to understanding the complexity of development. In particular, he stressed the
unsteady-state in which the fetus develops, being perturbed by transient changes in
behavioral state, ECoG activity, and hormonal release (Dawes 1985).
In remembrance of this meeting, David Mark Olson (Fig. 20.1h), of the University
of Alberta, has written,
…as a young scientist in 1984, I traveled to St. Catherine’s College, Oxford to attend my
first international fetal physiology symposium. The meeting was timed to coincide with
the retirement of Professor Dawes from his directorship of the Nuffield Institute. I was
amazed as I looked around at all the well-known fetal physiologists from the United
Kingdom, United States, Australia, New Zealand, The Netherlands, Canada, and else-
where who were in attendance. Why, I asked, were all these people here? Simple, I was
told. Most of these individuals either trained or spent a sabbatical with Dawes at the
Nuffield. Indeed, virtually an entire generation of fetal physiologists at one time or another
performed research in Oxford, many with Dawes. And from these scientists a second
19.3 The “Dawes Symposium” and Others 427

generation of fetal physiologists were being trained or established in their careers. Many
were still investigating important questions explored by Dawes. Others had moved into
new fields of inquiry. All carried the legacy of Dawes.
(Olson 1997, p. 1382)

Also in conjunction with this meeting, Arne Jensen of the University of Bochum,
and at that time a Fellow at the Nuffield Institute, recalls,
At the end of my stay I was honoured to witness one of GSD great moments: At the occasion
of the Meeting on ‘The Physiological Development of Fetus and Newborn’, held in…his
honor… Finally, GSD was in a position to prove to the scientific community that his theory
concerning the governance of the fetal breathing reflex was correct. How important this
moment of personal triumph over the reviewers was for GSD, I became to sense in our uncount-
able daily rehearsals – since the onus was on me to present his precious data on the meeting. He
did not want to leave anything to chance. His caution climaxed when he pre-determined a ques-
tion to be asked in the discussion after my talk and even the person who should ask it. The smile
on GSD’s face could not have been brighter when things turned out as hoped for. Several
months later he stepped down from his position as Director and the Institute was closed.
(Letter from AJ to LDL, 15 April 2009)

As noted earlier, in his introduction to the symposium to honor G.C. Liggins

(Gluckman et al. 1989), Dawes reviewed “Mont” Liggins’ many contributions to
science and to life, including studies on the role of the fetal hypothalamic–pituitary–
adrenal axis in the timing of parturition, the role of glucocorticoids in development
of the lung, the value of antenatal glucocorticoid therapy in lung maturation in
women with impending premature labor, and others (Dawes 1989).
In what would be his last of such endeavors, the ever peripatetic Dawes also
helped to organize and moderate the 1989 symposium Fetal Autonomy and Adaptation
held at the lovely Villa Varigola in San Terenzo di Lerici, Italy (Dawes, 1990; Dawes
et al. 1990). Promoted as a two decade follow-up to the 1969 Ciba Foundation sym-
posium Foetal Autonomy, the participants reconsidered topics discussed at that
gathering such as the fetal cardiovascular function, the role of the fetus in the initia-
tion of parturition, fetal immunology, and its hormonal milieu. In his introduction,
Dawes stressed the continually changing fetal physiology during developmental
maturation and its transformational environment. As was typical, following each
presentation he raised provocative issues to consider in regard to the autonomy of
the fetus (Dawes et al. 1990).
With the goal of having his research be ever relevant to clinical problems, his gift
for synthesis of ideas, and clarity of presentation, it is not unexpected that Dawes
could be a popular and highly regarded keynote speaker at various clinical confer-
ences and society meetings. In addition to those already mentioned, such presenta-
tions included the Donald Paterson lecture delivered at the University of British
Colombia, Vancouver, BC, Canada (Dawes 1973), “The Roots of Today’s Perinatal
Medicine” Symposium held in 1984 in Zurich, Switzerland, the James A.F.
Stevenson Memorial Lecture at the University of Western Ontario, London, Ontario,
Canada (Dawes 1988), his 1995 special lecture to “The Society of Foetal Physiology”
(forerunner of “The Fetal and Neonatal Physiological Society”) in Malmö, Sweden
(see below), and others.
428 19 Dawes’ Contributions to Symposia and a Summing Up

Fig. 19.1 (a) Geoffrey S. Dawes CBE, March 1981. (b) Opening the Sunley Research Centre,
Charing Cross, London (1985)

19.4 A Summing Up by Dawes

In a thoughtful retrospective, Dawes recalled his early years in developmental

physiology, of having to bend his own glassware to cannulate blood vessels,
building “… his own amplifiers, stimulators and oscilloscope time bases, mainly
with war surplus items…home built camera…,” and his purchasing the “…first
programmable electronic calculator…in 1967, the first microcomputer in 1972.”
In addition he emphasized that, until 1970 funding from non- Nuffield Institute
sources was “trivial.”
Regarding the field of fetal physiology, Dawes observed,
When I first started working in this field I hoped that physiological mechanisms would
prove to be simpler in the fetus than in the adult. We would be free of the complexities of
postnatal life, without the need for temperature control, independent breathing, feeding,
exercise or weight-bearing, with limited visual, auditory or tactile stimuli. I hoped that with
one deft movement it might be possible to split open the oyster and find the single pearl of
truth at its centre. We’ve all found that oyster to be an onion. As you carefully peel away
one layer of truth you find another one beneath. The complexities are built in at the begin-
ning, to preserve each and every single cell; upon this is superimposed the integration of
physiological functions. With its recognition as a complex discipline, fetal physiology has
yet more to offer.
(Dawes 1984, p. 262)
19.4 A Summing Up by Dawes 429

He continued,
So what, in this competitive physiological world, has perinatal physiology got that those
other organ or tissue oriented fields have not? I think its weakness and much of its strength
lies in the degree to which it is still oriented to the integration of function, in whole animals
and man. As an international group we have specialized in the relationship of cellular physi-
ology to the whole animal, rather than concentrating on the cell itself. Of course there are
fashions in our subject. In my younger days we looked, with some cynicism, at the attempts
to describe vascular changes solely in terms of adenosine or of histamine, Kallikrein, sub-
stance P (which has survived), bradykinin, serotonin or angiotensin. To these we may now
add the prostaglandins, the intestinal hormones, opiates and the other neurotransmitters
acting directly or indirectly. It is a nice problem to pick out which to study in relation to our
favorite pastime, the subject area we chose or had thrust on us by a supervisor, in which we
have made a big investment and from which it may not be easy to escape. It is the interplay
of relationships, the insight which comes from looking at the results in related fields (even
those concerned with monoclonal antibodies) which makes the subject so fascinating. Its
weakness is in the degree to which analysis of cellular mechanisms must be foregone in the
pursuit of its strength, the integration of functions.
(Dawes 1984, pp. 262–263)

Dawes then continued, pointing to several specific areas of cell biology that
demanded attention. His examples included the function of placental and fetal
tissue cell membranes, the mechanisms of chemo- or baro-receptor signal trans-
duction, vascular smooth muscle signaling mechanisms, and the neurobiology of
the developing brain (Dawes 1984). In conclusion, Dawes observed that “the
behaviour of the fetus, like that of the adult, not unexpectedly differs in sheep and
man. But a deeper understanding of the one helps that of the other, in both direc-
tions. It is a topsy-turvy situation…” (Dawes 1984, p. 263). Later, he wrote the
“…more that is learned about the general features of fetal physiology, the prob-
lems have become more complex, not simpler.” In a concluding soliloquy, he
stressed the importance of discovering knowledge of the physiology of the fetus,
to achieve an understanding of clinical problems such as premature birth, cerebral
palsy, and other conditions. Commenting on the link between perinatal physiolo-
gists and clinicians, Dawes noted, “Though their primary interests may differ,
there is a broad area of common knowledge and concern that deserves fostering”
(Dawes 1994, p. 5).
In 1985, the Nuffield Institute was commencing its sixth decade of existence as
a bastion of activity and a beating heart of academic life. Rather than celebrations,
however, because of limited funding, Oxford University officials elected to shutter
the Institute, and abolish the position of Director (Anonymous 1985). (As an aside,
despite a number of inquiries, I have been unable to unearth details regarding this
decision). Thus, at age 67, and 37 years after being appointed director, Dawes was
forced to retire from the Nuffield Institute. Its research program then became
focused on molecular biology. His restless mind not allowing the ease of a sedentary
life, Dawes became Director of medical research at the Charing Cross Sunley
Research Centre at Charing Cross Hospital, London (Fig. 19.1b) (Subsequently, the
Sunley Research Centre was incorporated into “The Mathilda and Terence Kennedy
Institute of Rheumatology Trust” (http://www.kirtrust.org)). In his position at
430 19 Dawes’ Contributions to Symposia and a Summing Up

Table 19.2 Dawes’ awards and honors

Year Award
1963 Max Weinstein Award, USA
1966 Gairdner Foundation Award, Canada
1969 James Spence Medal, British Paediatric Association Fellow,
Royal College of Obstetricians and Gynecologists
1971 Fellow, Royal Society, London
1972 Fellow, Royal College of Physicians
1974 Fellow, American College of Obstetricians and Gynecologists
1976 Fellow, American Academy of Pediatrics
1981 Commander of the British Empire Blair Bell Gold Medal, Royal Society
of Medicine
1982 Honorary DMed University of Gothenburg, Sweden
1990 Osler Memorial Medal, Oxford University British Design Award

Charing Cross, Dawes continued his work on computerized analysis of the fetal
heart rate and breathing movements. He strove continuously to foment, “A
Revolution at the Bedside.”
Dawes’ bibliography contains 238 published scientific papers (abstracts not
included). According to the ISI Web of Knowledge, 259 published items (including
some abstracts) in their database have been cited 11,532 times, giving Dawes an
“h-index” (number of papers that have been cited that many times) of 62 (http://
apps.isiknowledge.com, November 2012). As evidenced by his bibliography, Dawes
collaborated with at least 143 colleagues/coauthors. Shown in Tables 20.1, 20.2,
20.3, 20.4, and 20.5 are the graduate students, post doctoral fellows, and others with
whom Dawes collaborated with by decade. Table 20.6 lists those individuals with
whom he most frequently coauthored papers, Christopher W. Redman and Joan C.
Mott heading that list with over 30 publications apiece. Seventy-three of Dawes’
publications were single authored.
Recipient of numerous awards and honors, among others Dawes received the fol-
lowing: James Spence Medal, British Paediatric Association (1969), Fellow, Royal
College of Obstetricians and Gynaecologists (1969), Fellow, Royal Society of London
(1971), Fellow, Royal College of Physicians (1972), Commander of the Order of the
British Empire (1981; the motto of which is “For God and the Empire”), (Fig. 19.1a)
Blair Bell Gold Medal, Royal Society of Medicine (1981), Osler Memorial Medal,
Oxford University (1990), and British Design Award (1990) (see Table 19.2).

References

[Anonymous] (1985) Lord Nuffield’s baby victim of suffocating finances. The Oxford Times. 13
Sep, p 11
Bosma JF, Showacre J (eds) (1975) Symposium on development of upper respiratory anatomy and
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Bethesda, MD
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sudden death. In: Wedgwood RJ, Benditt EP, Burnett WM (eds) Sudden death in infants.
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Reuck AVS, Porter R (eds) Development of the lung. A Ciba Foundation symposium. Little,
Brown and Company, Boston, pp 297–311
Dawes GS (1969a) Introduction. In: Wolstenholme GEW, O’Connor M (eds) Foetal autonomy.
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6:259–265
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(eds) The physiological development of the fetus and newborn. Academic, London, pp
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behavioural patterns. Can J Physiol Pharmacol 66:541–548
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NY, pp 1–12
Dawes GS (1990) Fetal autonomy and adaptation. In: Dawes GS, Borruto F, Zacutti A, Zacutti A
Jr (eds) Fetal autonomy and adaptation. Wiley, Chichester, pp 1–4
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Chichester
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Chapter 20
Dawes as a Mentor: Reminisces of Former
Graduate Students, Postdoctoral Fellows,
and Associates

For many of us, academic medicine is one of the highest callings that one can
pursue in life. To chair, develop, and direct a major institute at a great university
shares that unique privilege. Among academic leaders in developmental physiol-
ogy and the reproductive sciences few have surpassed Geoffrey S. Dawes, one of
the outstanding leaders in the field. Many terms could be used to describe Dawes:
celebrated administrator, doyen of physician-scientists, illustrious, innovative, and
creative investigator, distinguished world authority in the reproductive sciences,
author of a foremost volume on developmental physiology, outstanding role
model, and friend.
A term that, I believe, encapsulates his career is mentor. As you recall from The
Odyssey by Homer, when he left Ithaca for the Trojan War, Odysseus chose as a
guide for his son Telemachus his friend Mentor. Like Mentor of Greek mythology,
Dawes dedicated his career to the development of young reproductive endocrinolo-
gists and investigators both clinicians and basic scientists. Without doubt, to a great
extent it was through the commitment, dedication, and perseverance of Geoffrey
Dawes that the field of developmental physiology came into its own. In helping to
educate and transform the lives and careers of a generation of young scientists, his
leadership helped to mold the field into one of the most academically exciting.
As noted by John Challis in his Foreword, Geoffrey Dawes, the demiurge behind
the creative contributions at the Nuffield Institute, served as a wise and trusted
teacher and inspiration to a large number of protégés, graduate students, postdoc-
toral fellows, and other colleagues. Many of these went on to become highly pro-
ductive, scientists and leaders in their own right. For over four decades, life at the
Nuffield Institute embodied a halcyon era. Tables 20.1, 20.2, 20.3, 20.4, and 20.5,
list these individuals by decade, with the number of publications coauthored with
Dawes in parentheses. Table 20.6 lists those collaborators with whom he published
most frequently.
Clearly, Dawes possessed a number of strengths and passions. Although at times
he could be quite “difficult,” yet he glowed with an intellectual sheen. One of his
major gifts was his upholding of “translational” or clinical applications in the

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 433
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_20, © American Physiological Society 2013
434 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

Table 20.1 Mentor for graduate students, postdoctoral

fellows, and other collaborators—1950s
Investigator Publications
G.H. Acheson 1
E.C. Amoroso 1
Gordon M. Ardran 1
Gwenda Barer –
Gustav Victor Rudolf Born 5
Julius H. Comroe Jr. 1
Kenneth W. Cross 1
J.J. Handler 1
Joan C. Mott 23
Marjorie M.L. Prichard 1
Barbara R. Rennick 3
Samuel Robert Means Reynolds 1
Heather J. Shelley 1
John R. Vane 2
John G. Widdicombe 10
Derek G. Wyatt 2

forefront of his thoughts, such that a number of his contributions to physiology

proved to be of considerable importance to perinatologists and neonatologists.
Truly, his was a life well-lived.
Personally, Dawes was focused, scientifically rigorous, uncompromising, logical,
energetic, and often generous in praise to others. In the mid 1960s, I first met him as a
fellow participant at one of the Princeton Fetal Homeostasis conferences. From thence
and for over three decades of interacting at international meetings together, and with
several visits to the Nuffield Institute, I always was struck with his breadth of knowl-
edge and abilities as a polymath. As a discussant at scientific meetings, truly remark-
able was his capacity to expatiate with confidence across a remarkable spectrum of
biological science. Following a presentation he would rise, and cut to the heart of the
topic under consideration, expounding at length about many aspects of the issue, con-
sidering alternative hypotheses for accepted paradigms, and concluding with one or
more critical questions to consider. He thrived in the hot house of focused discussion,
new ideas, and debate. Upon learning about some exciting new work, often a beatific
smile would spread across his face. Over the three decades of our interacting at meet-
ings, we corresponded frequently. Often he would inquire about some aspect of a study
we had reported, and request a copy of the offprint for his file. Not infrequently, in
commenting upon the work, Dawes would conclude with “Good Work!” “What Fun!”
Particularly impressive was Dawes’ enthusiasm for, and commitment to, the
young people who worked with him at the Nuffield Institute. As evident from the
reminisces recorded earlier, he could be magnanimous in spirit and generosity. He
also was keen to support those who returned to their home institutions, helping to
launch them on a successful career. In observing Dawes and his interactions with
those under his tutelage, philosophically, he was what is sometimes referred to as an
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 435

Table 20.2 Mentor for graduate students, postdoctoral

fellows, and other collaborators—1960s
Investigator Publications
Karlis Adamsons 2
Richard E. Behrman 2
A.J.M. Campbell 6
Sidney Cassin 2
H.J.H. Colebatch 1
F. Cockburn 2
Kenneth W. Cross 3
S.S. Daniel 3
M.J. Dawkins 1
Alfred P. Fishman 4
J.W. Goodwin 1
E. Hibbard 1
A.I. Hyman 6
H.N. Jacobson 2
G.B. James 1
L. Stanley James 5
C. Koford 1
B.V. Lewis 3
C.L. Merlet 2
G. Mestyan 1
J.E. Milligan 2
Joan C. Mott 7
R.E. Myers 1
R.A. Nadeau 1
W. Niemann 1
J.B. Owen-Thomas 2
H.B. Parry 1
H.M. Perks 1
J.T. Reeves 2
Margot R. Roach 1
H. Rodriguez de Curet 1
B.B. Ross 6
Heather J. Shelley 4
A. Stafford 2
L.B. Strang 1
N.S. Talner 1
William F. Windle 2

“educational perennialist.” That is, one who strives to teach that which one deems
to be of everlasting importance for life, to stress principles rather than specific facts,
to help develop an individual’s mind to reason scientifically, and thus to stand out as
a true leader in the world of investigators and academic medicine.
Regarding some aspects of Dawes’ mentorship, the late John G. Widdicombe of
London, who worked at the Nuffield Institute in the 1950s, wrote,
436 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

Table 20.3 Mentor for graduate students, postdoctoral

fellows, and other collaborators—1970s
Investigator Publications
P. Bailey 1
Kenneth Boddy 3
E.S. Boyce 1
R.L. Chapman 1
J.B. Clegg 2
K.J. Dalton 2
R.L. Fisher 2
Harold E. Fox 2
J.D. Gough 1
Bernard M. Leduc 1
Graham C. Liggins 1
C.L. Merlet 1
J. Nash 1
John E. Patrick 2
K. Pearce 1
S. Pinter 2
E. Robin Poore 1
Robert T. Richards 3
Jeffrey S. Robinson 5
Geoffrey D. Thorburn 2
D.J. Weatherall 2
W.G. Wood 2

In his early professional days at Oxford, Geoffrey was nicknamed ‘the Bishop’. This had a
grain of truth in it. His demeanour did at times seem serious and pontifical, but this hid a
great sympathy and affinity with his audience. He certainly took great care of his ‘flock’ of
young scientists, both scientifically and socially. His home in Belbroughton Road, North
Oxford, was famous for the parties he and his wife Margaret gave, at which we were all
made to play childrens’ games.
(Letter from JW to LDL, 20 March 2009)

In regards to his research, Widdicombe recalled,

[My] work on reflexes from the airways was nearly a nonstarter. In … [the early 1960s] it
took eight weeks to get a licence to do animal research (now it takes eight months) and, to
fill the time, Geoffrey advised [me] to read all about the oesophagus (‘the most neglected
tube in the body’) as a preparation for research for a D. Phil. After eight weeks [I] told
Geoffrey that [I] found the oesophagus dull and the bronchi fascinating; ever positive and
encouraging Geoffrey agreed that the bronchi should be the basis of [my] research.
(Letter from JW to LDL, 20 March 2009)

Widdicombe also noted Dawes’ thoughts regarding collaboration with

clinicians,
From the outset Geoffrey had the wisdom to foster relations with clinicians (including the
thoracic surgeon Phillip Allison and the physician Hugh Cairns) at a time when many phys-
iologists considered clinical departments unworthy of scientific acknowledgement. [I] had
Table 20.4 Mentor for graduate students, postdoctoral
fellows, and other collaborators—1980s
Investigator Publications
K.J. Anand 1
O.S. Bamford 5
Richard Belcher 3
Carlos E. Blanco 4
R.L. Chapman 1
F. Clewlow 3
P.M. Cotes 1
K.J. Dalton 1
R. Denny 1
W.N. Gardner 2
J.G. Gianopolus 1
M.D.G. Gillmer 1
Jonathan D. Goodman 7
Keith R. Greene 1
Mark A. Hanson 2
R.A. Harkness 1
D.J. Henderson-Smart 1
G.L. Henson 2
G.J. Hofmeyr 2
T.A. Howlett 1
C.R. Houghton 2
Arne Jensen 1
Barbara M. Johnston 5
Brian J. Koos –
G.W. Lawson 3
D.H. Levine 3
H. Lilja 1
H.B. McCooke 2
Renato Natale 1
M.J. Parks 1
John E. Patrick 1
L.C. Pello 1
Christopher W. Redman 14
L.H. Rees 1
K.G. Rosen 1
Dan W. Rurak 1
J.H. Smith 4
J.A. Spencer 1
G.S. Sykes 1
I. Thaler 1
G.H. Visser 9
J.I. de Vries 1
David W. Walker 7
R.A. Ward 3
A.M. Wheble 1
P.J. Wickham 1
P.L. Wilds 1
H.J. Zeelenberg 1
438 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

Table 20.5 Mentor for graduate students, postdoctoral

fellows, and other collaborators—1990s
Investigator Publications
O.S. Bamford 1
P.J. Bowell 1
G. Conoscenti 1
Nicholas W. Dawes 1
P.J. Ferguson 1
M.O. Lobb 2
I.Z. Mackenzie 1
L.A. Magee 1
G.P. Mandruzzato 2
Y.J. Meir 1
M. Moulden 16
L.C. Pello 2
G. D’Ottavio 1
Christopher W. Redman 18
S.K. Rosevear 2
O. Sheil 1
P. Street 1
M. Selinger 1
V. Serra-Serra 1
T. Wheeler 2

wanted to start physiological research immediately after his science degree, but Geoffrey
was firm. ‘Get medical degrees first, and I will keep a place for you’. His advice was, as
always, very sound. Geoffrey initiated Nuffield research fellowships for visiting physicians,
who came from all over the world. This led to many fruitful links between basic research
and advances in clinical practice.
(Letter from JW to LDL, 20 March 2009)

From the University of British Columbia, the 16th Baron of Corcomroe, Anthony
Manning Perks has written of working with Dawes at the Nuffield Institute in the
mid-1960s.
I greatly enjoyed my years with Geoffrey in Oxford. He was a kind and supportive friend. I left
the Nuffield Institute with great regrets, but my wife, from Pennsylvania, hated Oxford, in part
because the University turned down her application for graduate study: I wanted to save my
marriage (it did not). Vancouver was a great compromise between England and the States.
Geoffrey looked disappointed when I gave him my resignation, but I think he had anticipated
it: I had been there as his “permanent” endocrinologist. My new post, in Zoology at the
University of British Columbia, gave me wide latitude in research, and I enjoyed my task of
teaching medical subjects on Campus, in the Faculty of Science. Geoffrey came through in
those early days, to open the new Research Division in Obstetrics and Gynaecology, a division
started by two of my own students, including … Dan Rurak, who had gone from a Masters
with me to do a D.Phil with Geoffrey. Geoffrey was enthusiastic about our work on the amnion.
(Letter from AMP to LDL, 23 April 2010)

Baron Perks continued with other personal reminisces,

20 Dawes as a Mentor: Reminisces of Former Graduate Students… 439

Table 20.6 Top co-authors with Geoffrey S. Dawes

Investigator Publications
Christopher W. Redman 32
Joan C. Mott 31
M. Moulden 17
John G. Widdicombe 10
G.H. Visser 9
O.S. Bamford 8
Jonathan D. Goodman 8
David W. Walker 7
A.I. Hyman 7
Jeffrey S. Robinson 7
A.J.M. Campbell 6
L. Stanley James 6
B.B. Ross 6
Barbara M. Johnston 5
Gustav Victor Rudolph Born 5

As to Geoffrey Dawes himself, he was a wonderful boss, kind and considerate, and always
interested in what you were doing. However, one personal memory keeps coming back.
During surgeries he would suddenly disappear below the surgery table. No-one said any-
thing. Geoffrey suffered from asthma, and he was taking a puff from his inhaler—but he
never wanted people to see him doing it. Also, at those times, Geoffrey would deliberately
drive Alfred P. Fishman [(1918–2010)] mad. He would ask what should be done next; Dr.
Fishman would give an entirely sensible suggestion. Geoffrey would immediately reject the
good suggestion, and do something entirely different. This did not lead to blows (but some-
one like me did wonder about it). You see, Geoffrey knew the results they had found the
previous year; Fishman did not!
(Letter from AMP to LDL, 23 April 2010)

Eugenie Ruth Lumbers, (Fig. 20.1d) of the University of Newcastle, Australia,

wrote regarding her time at the Nuffield Institute working with Joan Mott during the
late 1960s and early 1970s,
Joan was one of the most generous people I have ever met and I was very fond of her. She
organised a fellowship for me at Wolfson College which resulted in some of the most excit-
ing experiences in my life. Oxford was for both of us (Bill, my husband and I; I am not sure
about the 2 very young children) one of the loveliest times of our lives and it was largely
due to Joan Mott. The Nuffield Institute was a very interesting environment. Geoffrey
Dawes was in his prime and research wise it was growing as we generated the technologies
for studying the fetus in utero (Joan would never accept foetus—it is a mixture of Greek and
Latin and fetus is 4th declension Latin as I assume you know). I remember Geoffrey and
Joan having an argument over using fetusas both singular and plural vs fetuses. But it was
a meeting place of international research, of fun (singing American Pie/or was it Hi Hi Miss
America Pie? With the crowd from the Nuffield) and many many other happy memories.
Then there was the international visitors who we met through the Nuffield …
To me Nuffield was my introduction to the international world of research, something you guys
from the USA or from the UK would never appreciate to the same extent as a woman (shock, hor-
ror) coming from the Antipodes. I was fond of Geoffrey but concerned about his attitudes to
women like Joan and Heather Shelley. At the same time I feel that his contribution to fetal physiol-
ogy was great, as great as … others who contributed so much to establishing this discipline.
440 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

Fig. 20.1 (a) Michael Parkes, Arne Jensen, Geoffrey Dawes and Justin Hofmeyer (Oxford, ca.
1984). (b) John R.G. Challis. (c) Gerard H.A. Visser. (d) Eugenie Lumbers with Andrew Stevens
(ca. 1990). (e) Geoffrey D. Thorburn with Jeremy Sigger. (f) David W. Walker. (g) Kent L.R.
Thornburg. (h) David M. Olson. (i) Richard Harding (ca. 1990). (j) Brian J. Koos. (k) Mark A.
Hanson. (l) Dino A. Giussani. (m) Mark A. Hanson and Dino A. Giussani. (n) Charles E. Wood.
(o) Dan Rurak, Robert Creasy, and Dawes. (p) Dawes fishing
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 441

Fig. 20.1 (continued)

442 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

Fig. 20.1 (continued)

20 Dawes as a Mentor: Reminisces of Former Graduate Students… 443

Fig. 20.1 (continued)

444 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

Now when the fetal origins of adult disease have assumed their significance in terms of
the study of human health and disease to an extent that we can see its role in the aetilogy of
end stage renal disease in indigenous Australians and I hope we can set in place measures
that will reduce the incidence of this shocking epidemic in our indigenous populations and
raise their life expectancy to that of Caucasian Australians, I realize that Geoffrey Dawes,
and others laid the foundation stones of a discipline that can make a magnificent contribu-
tion to human health and I haven’t even begun to talk about the improvements in neonatal
care—the knowledge base is just too big thanks to you pioneers.
(Letter from ERL to LDL, 16 September 2009)

Later, Lumbers sent a photo of her at the Nuffield several decades earlier.
Yes, I am younger here and not so wrinkly BUT I have a good excuse, apart from the
Australian sheep who is beautiful, the gentleman in the background is Andrew Stevens.
Andrew worked for many years at the Nuffield under Geoffrey and especially in the chronic
sheep work so many old Nuffielders will remember him. Andrew came to Australia (he had
married Denise Madill who also worked at Nuffield) and joined my fledgling research
effort. Together we got my chronic sheep work going—we had sheep in offices, in sheds
etc. until we finally were recognized and got some space of our own. Andrew did a PhD
under my supervision. He is now retired and lives on the South Coast of New South Wales.
Denise has retired but has quite an outstanding reputation in textiles and weaving. I am
meant to be retired but am involved in four research projects ranging from neonatal piglets
to human studies. My biggest interest is trying to work out the role of the intrauterine renin
angiotensin system in pregnancy—in particular the prorenin-renin receptor system. Having
described prorenin in human amniotic fluid many many moons ago I would like to find out
what it does before I fall of the perch.
(Letter from ERL to LDL, 21 September 2009)

Gordon Gilbert Power of Loma Linda University remembers,

Often, in the early sixties, Geoffrey was a lonely pioneer at lung meetings trying to interest
pulmonary investigators in his studies of the placenta and oxygenation of the fetus. It was
an uphill battle, to say the least, but he was persistent and articulate. His 1968 book, of
course, had a great impact in legitimizing the field of fetal physiology and establishing it as
an independent discipline.
I recall that at one International Conference, Geoffrey and I were alone in a garden
outside a convention center. There, in private, we fell into conversation and he said, “Well,
do you have any new ideas for your research?” I responded, “Well, lets see, we’re thinking
that perhaps carbon dioxide plays a major role in the regulation of fetal cardiac output—it
forms bicarbonate and pulls in water from the mother by osmotic force to increase fetal
blood volume.” Geoffrey replied, “Well, no, I don’t think that’s right. You’re on the wrong
track. And besides, I thought after my work there weren’t any new ideas left to explore
anyways.” He prided himself for being the leader in the field, and he was sensitive if this
was not always duly recognized as such.
(Letter from GGP to LDL, 28 November 2011)

In addition to his Foreword, John Challis (Fig. 20.1b) Professor Emeritus of the
University of Toronto, and President and CEO of the Michael Smith Foundation for
Health Research, Vancouver, British Columbia writes on fetal research in Oxford,
In the mid 1970s Oxford was one of “the” places for fetal physiology research. Later some
called it the Camelot period of research in our specialty. We had the availability of the
chronic fetal sheep preparation, the ability to measure small concentrations of hormones
using sensitive radio-immunoassay, sympathetic funding agencies, a public that was inter-
ested in the development of the baby, and in Oxford an extraordinary collection of great
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 445

minds, superb mentors and enthusiastic fellows and young faculty assembled together at the
same time. The proximity of the Nuffield Institute for Medical Research (NIMR) with the
John Radcliffe Hospital and the Nuffield Department of Obstetrics and Gynaecology cre-
ated the environment for interaction between basic scientists and physicians and the appli-
cation of basic research to problems of clinical importance.
In 1974 there were three main research groups in fetal physiology at Oxford, headed by
Geoffrey Dawes, who was Director of NIMR; Alexander Turnbull (later Sir Alexander
Turnbull), the Nuffield Professor of Obstetrics and Gynaecology, and Geoffrey Thorburn
(Fig. 20.1e). Geoff Thorburn had earlier been a sabbatical visitor with Geoffrey Dawes
and had been persuaded to stay in Oxford, with salary provided through the British Medical
Research Council (MRC). Geoff Thorburn’s role was to help facilitate the transfer of
knowledge between NIMR and the hospital. Jeffrey Robinson and I worked with him, sup-
ported through an MRC program grant. Our labs were in the hospital, but our animal studies
conducted in the Institute. The corridor between the two, affectionately known as the
“umbilical cord”, was a conduit for great ideas although at times could be rather cool, in
different ways.
The other two groups also had Medical Research Council program grants in addition to
individual grants. Geoffrey Dawes of course held a major program grant at NIMR, where
the staff included C.T. Jones, Joan Mott, Derek Myatt, John Bassett and a group of highly
enthusiastic overseas fellows, Knox Ritchie, David Walker, John Patrick and Dan Rurak a
Canadian DPhil. student with Geoffrey. Across the bridge, Alec Turnbull’s group included
Anne Anderson and Tony Flint, a young DPhil. student Murray Mitchell, senior academics
including Mostin Embry and John Bonnar, and a string of enthusiastic young clinical train-
ees including Andrew Calder, Ian McKenzie, and … Chris Redmond. There was unques-
tionably an intense, if good spirited, rivalry between our three groups. That helped our
individual research, ensuring that it had been subjected to intense internal scrutiny before
presentation outside the Institute, but it also brought us all together in collective pride. This
was so evident in circumstances of competition with Cambridge and the team of Robert
Comline, Marion Silver and the young Peter Nathanielsz, and with San Francisco, with Abe
Rudolph, Michael Heymann and Joe Kitterman.
Geoffrey Dawes had reported on the occurrence and regulation of fetal breathing move-
ments in the sheep (a paper with “Mont” Liggins as co-author), and continued outstanding
studies on fetal cardiovascular control mechanisms. The acute fetal sheep preparation was
still used at the Institute, but the development of the chronic fetal sheep prep had opened up
a whole new field of opportunity. We knew that we were achieving a very high success rate
with this preparation, attributable to the skills of the surgical teams and the meticulous
attention to sterile technique and monitoring, but also to the superb work of Harry Elvidge
the Chief Technician in the animal care facility at NIMR. There were three venues for the
scientific discussion and academic discourse. The most formal were clinical rounds in hos-
pital, where Geoffrey would often attend to ensure that young obstetricians were aware of
the fundamental scientific principles underlying their clinical practice and that they prac-
ticed evidence-based medicine to the extent possible, and well before that term acquired
broad usage.
The second forum for discussion was the large round table situated in the open area at
the end of the umbilical corridor to the hospital. At morning coffee, Geoffrey Dawes would
hold forth about new ideas and new avenues of research and often launched into a tutorial
on various aspects of fetal physiology. Thirty years of being a Senior Oxford Don had
molded his character. Pushing back his mop of hair he was a powerful debater and at times
a fearsome teacher. I had arrived in Oxford via a PhD in Cambridge (with Brian Heap, now
Sir Brian Heap) and a post-doc in San Diego and at Harvard with the late Kenneth J. Ryan.
I had aspirations of becoming an endocrinologist which in Geoffrey’s mind was ‘okay’, so
long as I did not consider myself to be a real physiologist. Soon after my arrival at Oxford
he asked me across the large round table and in front of the assembled group of morning
446 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

coffee drinkers if I could explain some of the physiological responses of the fetus to hypox-
emia. It was clearly a test and a challenge. Fortunately I must have muttered a sufficiently
acceptable response that I was allowed to stay. When we made the first measurements of
prostaglandin concentrations in the circulation of the fetal sheep and showed that there were
extraordinarily high concentrations of PGE2 which rose at the time of labour I had suffi-
cient courage to show these to Professor Dawes. Actually I made the mistake of showing
him the raw data coming off the scintillation counter. The counts went down as the concen-
tration of PGE2 was going up. I could see he was unimpressed until it occurred to him that
these changes might have something to do with the decline in fetal breathing movements at
the time of labour. Our relationship was fine after that.
Our third venue for discussion was of course the pub at lunchtime. I laugh that we now
have to create a formal setting for lab meetings at a prescribed time each week. In Oxford
in the mid 70s there was a lab meeting everyday; at coffee time, and at the “White Hart” at
lunchtime. I became great friends with John Patrick in the course of those “lab meetings”.
The three Geo(Je)ffrey’s (Dawes, Thorburn and Robinson) were inevitably part of the
group. There was often a vigorous, sometimes furious exchange of views about the day’s
experiments, speculation about results and their interpretation, and a rich abundance of new
ideas and new directions. I learned quickly to respect and indeed be amazed by Geoffrey
Dawes’ extraordinary breadth and depth of knowledge across different areas of physiology
and admired his ability to pull in pieces of apparently unrelated information to generate a
coherent story.
As I was leaving Oxford to move to Montreal, Canada, I had a final formal meeting with
Geoffrey Dawes in his office. It had been a difficult decision for me to leave Oxford but
ironically the richness of the environment and one’s continuous exposure to new ideas left
a need to demonstrate, at least to oneself, an ability to be sure that one could create one’s
own original thoughts. Without saying so, I think that Geoffrey understood. He passed on
two messages. “John”, he said staring at me with those penetrating little eyes, “you should
be sure to learn and publish a new major technique every year” then he added, “and John,
publish less.” It took me some time to understand what he meant by that last remark but then
I remembered that I was an endocrinologist and in Geoffrey’s view endocrinologists were
enthusiastically applying the newly evolving radio-immunoassays to every tissue and fluid
available. In his view, we needed to think more and strive to publish the highest quality
papers in the very best journals.
Finally I must comment on another side of Geoffrey Dawes. Professionally, he had
acquired the reputation of a brilliant experimentalist with extraordinarily high standards
and quality of research. But he could be ruthlessly demanding, and critical if others did not
meet those same standards. There was also a softer, gentle kindness to Geoffrey Dawes as
well. I remember a dinner party at Geoffrey’s house in north Oxford where this very famous
man became a caring and obviously loving husband to Margaret and was at her side
throughout the evening. He had enormous respect for Geoff Thorburn and when Geoff was
ill, Geoffrey showed great concern and compassion. He helped me, I am sure once I had got
the hypoxia question right, win a Junior Research Fellowship at Wolfson College and I have
no doubt that his supportive hand was there unsolicited and undisclosed at other times.
Finally, it was of course through Geoffrey Dawes and Geoff Thorburn that I had the privi-
lege of meeting the young John Patrick. Geoffrey Dawes held John in very high regard.
Here was a young obstetrician who was clearly a thinker, a leader with unrivalled enthusi-
asm to take on the experimental approach and to pursue the results of animal studies in
human subjects. By 1980 both JP and I were working together in London, Ontario. Geoffrey
Dawes would always visit us if at all possible during his trips to North America. I recall one
time standing at the airport in London, Ontario with John Patrick waiting for Geoffrey to
arrive. His plane was late and the SGI abstract deadline was fast approaching. John and I sat
down and wrote our abstract on the back of a brown paper bag from Tim Horton’s Coffee
Shop. We laughed and showed it to Geoffrey when he finally arrived. The research con-
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 447

cerned diurnal rhythms of steroid hormones in pregnant women. It was not exactly
Geoffrey’s area of interest, but he made a couple of suggestions and said he thought it might
make a reasonable presentation. To our great surprise the paper was selected for the
President’s Plenary Session at the Annual Meeting of SGI the following March. Geoffrey
became aware of this, and took time to send us a very kind note of congratulations.
Geoffrey Dawes was a great visionary who helped to open up a new field of research and
a new foundation to clinical practice. He was a great teacher, and underneath that tough exte-
rior was a sensitive and compassionate man. His legacy of course is not just his science, but
his impact on the succession of colleagues and young trainees who were influenced by him.
(Letter from JRGC to LDL, 8 January 2010)

Also from Canada, and the Mount Sinai Hospital, University of Toronto, James
Whiteford Knox Ritchie wrote of the early 1970s.
The whole era was, of course, very exciting and established the scientific evidence for much of
what we do today. Oxford of that time has been described as a “Camelot”. There were so many
great names [that] came through the department and so many young people came for scientific
training and went on to become significant investigators—or chairs [around] the world.
I was there for 2 ½ years from 1973–1975. I remember being interviewed by Geoffrey
for the position—then we went to the pub. There, out of the blue, he looked at me and asked
why the fetus breathes intermittently. Having read his book on the way to the interview I
thought I had missed something important, and not knowing the answer would be the end
of the job. Little did I know that no-one knew at that time—he was just looking for some
intelligent reply which I don’t think I managed. He could be quite intimidating until you got
to know him!
(Letter from JWKR to LDL, 1 February 2010)

Following completion of his residency in obstetrics and gynecology at Harvard’s

Boston Lying-In Hospital, Brian John Koos (Fig. 20.1j), of the University of
California Los Angeles, spent 3 years at the Nuffield Institute. He recalls,
In 1979, I began a research fellowship under the auspices of the NIH with Geoffrey Dawes
at the Nuffield Institute for Medical Research at the strong recommendation of my mentor
Lawrence D. Longo. Thrilled to be able to work with such an internationally acclaimed
authority on the fetus, I aspired to earn a D.Phil. under his tutelage. While understandably
reticent to support such a commitment, Geoffrey eventually endorsed my matriculation at
Oxford University, but there was one condition—that I ride a bicycle like the other
students.
In the first year, my family and I lived Woodeaton, a hamlet a little more than three miles
from the Nuffield Institute. Every morning I set out just before 7, pedaling down a winding
lane through paddocks to Marston Lane and then up a hill via Headley Way to the Institute.
On many occasions, as I strained to pump my ancient, rusting bike up the hill, Geoffrey
would pass me in his shiny new Saab, honking and waving with a wide grin. I have often
thought that Geoffrey was quite pleased with himself for making an American physician
ride a bicycle!
(Letter from BJK to LDL, 23 December 2009)

Also from the late-1970s to early-1980s, Gerard Hille Adriaan Visser (Fig. 20.1c)
of Utrecht, the Netherlands has written,
I arrived in August 1978 to spend a Royal Society Fellowship year at the Nuffield Institute.
During my first meeting with Geoffrey, he carefully managed to situate me facing the light,
some strategic planning that appeared to be a consistent part of his behaviour, even in situ-
ations where he had to maneuver himself in some dark corners, opposite to chairs that were
448 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

at easy access. Some power play; it was obvious that he was the boss. My first name,
Gerard, was too Victorian according to him. So I became Gerry, all over the world, except
for the Netherlands.
Two years earlier Geoffrey had gained interest in the human fetus. Before that time it
was mainly sheep. Fetal breathing and numerical analysis of fetal heart rate (FHR) patterns
were his focus at that time and I could join the team, with Chris Redman (obstetric physi-
cian) and Jonathan Goodman (Senior Registrar Obstetrics and Gynaecology and ultrasound
expert). The fact that human fetuses did not behave like sheep fetuses frustrated Geoffrey.
A sheep fetus does not breathe during quiet sleep (High voltage low amplitude EEG.) and
it demonstrates an increased heart rate variability during hypoxaemia. A human fetus con-
tinues to breathe during quiet sleep and demonstrates a reduction of FHR variation in case
of (chronic) hypoxaemia. The latter difference with sheep can partly be explained by differ-
ences between acute and chronic hypoxaemia, the first appeared to be a frustrating species
difference.
It was amazing how Geoffrey, he must have been 60 at that time, managed to start
writing computer programmes on prehistoric devices to tackle antenatal FHR patterns. That
was not easy given the presence of shifts in baseline FHR, and different implications of
periodic … accelerations and … decelerations. This hampered the use of SD [standard
deviation] as a measure of FHR variation with time. No, first baseline recognition, and
subsequently analysis of variation after exclusion of decelerations. The antepartum FHR
program developed in that period is still … in clinical use in obstetrics. He did not succeed
in developing a similar program for intrapartum FHR monitoring, and no one else has
managed to do so since then. Geoffrey was a skilled mathematician, a trait inherited from
his father.
Geoffrey was a good teacher, especially to us foreigners. After writing a paper and dis-
cussing it with him, he commented once, ‘so now the real problem starts’. That appeared
strange to me, proud as I was that he had approved my intellectual efforts. But of course,
each result contains a new problem: why, what is the patho-physiological background, what
if…, etc etc. This has stayed with me ever since, just as his clear style of writing. Quoting
Chris Redman in an obituary on Geoffrey (either from the Times or Independent) “He had
a terse synoptic style of writing, clear and economical; sometimes he had to be reminded
that his readers’ mind were not as quick and logical as his own and so be persuaded to insert
what he considered to be unnecessary elaboration and explanation”. From the same obitu-
ary: “He retained astonishing vigour, openness to new ideas, a precise and detailed memory
and an unremitting dislike for thoughtlessness and ignorance. His encounters with the latter
stimulated his asthmatic wheeziness, so it was a familiar signal of his mood when he angrily
had to use his inhaler”. Yes, that was Geoffrey.
The Nuffield Institute for Medical Research was the center of fetal and neonatal physi-
ology in those days. Either you were working there, with an extremely little desk in the
lecture hall, or you visited the place, gave lectures and had individual talks with the research
gang. The continuous intellectual challenge has stimulated many of the young researchers
to continue in the field of perinatal medicine. Peers were and remained those present in
Oxford beforehand or during those days.
In 1974 the first fetal breathing conference was organised by Geoffrey and the Swedish
obstetrician [Gerhard] Bo Gennser. Yes, the fetus was breathing, which was new after
Ahlfeld had suggested the presence of fetal breathing in 1903 and was therefore expelled
from his German society. I remember Geoffrey demonstrating the Doppler noises of fetal
breathing at the European Congress of Perinatal Medicine (ECPM) in Uppsala in 1976 (the
Fifth Congress). Later he got the maternity prize of the ECPM. The fetal breathing confer-
ences brought together obstetricians, neonatologists and physiologists, especially the young
ones and preferably those who had an Oxford history. Since you could not earn your money
with fetal breathing the conference was renamed the Fetal Breathing and Other
Measurements Conference in 1979 (and saw the first presentations on fetal Doppler blood
flow velocity measurements) and changed its name later in to: Fetal and Neonatal
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 449

Physiology Society, a name better suited to the contents of the meeting. This society is still
flourishing, first being chaired by Geoffrey, then by Bo Gennser, then by me, and thereafter
by Marc Hanson, Bill Parer, Laura Bennett and now by Jan Nijhuis. During all those years
100–140 mainly young scientists came together annually to present their preliminary work
on fetal and neonatal medicine; no official abstracts, but brief presentations and especially
lively discussions, with Geoffrey—when he was still around—as the mild Godfather, criti-
cal but also very stimulating. Rather unique of this annual conference was and is the sport-
ing event. Over the years the different countries have been competing on rowing, punting,
sailing, beach volleyball, spitting, football, croquet etc. In 1989 the final at the Great Barrier
Reef was played between Geoffrey and Mont Liggins (croquet). Mont won, which was dif-
ficult for Geoffrey. The Society is still very much awake and has been able to continue to
attract young people working in the field of perinatal medicine. Its 39th annual meeting will
take place in Utrecht, the Netherlands (my home town) in July 2012.
The ones of us who came regularly to Geoffrey and Margaret’s house at Belbroughton
road, saw a different man. A real gardener and family man, helpful in the kitchen and a very
good host. If you wanted to see his CBE, than he took you to his bedroom, pulled a suitcase
from under the bed and showed it to you. Margaret is almost 100 years old now and writes
her memoires about her early days in Malaysia. She has remained witty and intelligent. She
and the four children have always been the real driving force behind Geoffrey.
(Letter from GHAV to LDL, 16 January 2012)

Danny Rurak, (Fig. 20.1o) of the University of British Columbia, Vancouver,

who worked at the Nuffield Institute in the mid-1980s, testified to Dawes’ impor-
tance to his career. Rurak summarized many of the features that helped to make
Dawes’ mentorship and the Nuffield Institute a life changing experience.
I worked in the NIMR under Geoffrey’s supervision from 1972 to 1977, first as a DPhil stu-
dent and then as a post doctoral fellow. Without doubt is were those years spent in Oxford that
were the most important in terms of me becoming established as an independent investigator.
I am extremely grateful to Geoffrey and for the opportunity to work in the NIMR.
I first met Geoffrey in the fall of 1971, when I and some friends were traveling in
Europe. I had learned of him from Tony Perks, who was my MSc supervisor at UBC and
who had worked in Oxford at the NIMR for a while in the 1960s, along with Sid Cassin,
who he continued to collaborate with for many years. I wrote to Geoffrey before leaving for
Europe and arrange to visit him. I and one of the friends I was traveling with stayed for a
night at Geoffrey’s house on Belbroughton Street and I had a tour of the NIMR. I think that
was when I first met Colin Jones, Joan Mott and Fiona Broughton Pipkin. When touring
Joan’s lab, she described her work on the renin-angiotensin system in the fetus and men-
tioned the JGA [juxta-glomerular apparatus]. Geoffrey than asked me what JGA stood for
and fortunately I was able to provide the correct answer. In retrospect, I think that it was my
correct answer that led Geoffrey to accept me as a DPhil student.
In the years I spent at Oxford and also after leaving, I have thought a lot about what is
was about the NIMR that made being there be such a rewarding and valuable experience.
I think that the following factors were important.
1. Geoffrey himself, who was extremely bright in the Oxbridge way. He was an excellent
graduate student supervisor, in the sense that he left it mainly up to the student to
develop the research proposal and conduct the experiments. That certainly was the case
with me.
2. The amazing collection of clinical and basic science students, fellows and visitors who
worked in the NIMR. Over the time that I was there that included: Bob Bradley,
Charlotte Mistretta, Ken Boddy, Geoff Robinson, John Patrick, Kevin Dalton, Frank
Manning, Colin Mantel, Geoff Thorburn, John Bassett, John Challis, Knox Ritchie,
450 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

Roger Chapman, Lea Wilds, Richard Robinson, Fiona Broughton Pipkin, Barbara
Johnston, Richard Harding, Paul Johnson, David Walker, Graham Jenkin and Eugenie
Lumbers and many others whose names I have forgot. Working with them over the years
was very stimulating and rewarding and most of them have remained friends and col-
leagues to this day.
3. The camaraderie that was present among the “visitors”. Oxford for someone that comes
from outside, particularly from the “colonies” is initially a somewhat intimidating place
and this certainly applied to the NIMR. I found that you have to work there for a year or
so, before you were accepted or even acknowledged by “Old Guard”—the permanent
faculty. As all of the visitors were in the same boat, we joked about it and kept together
as a group that also included the technical staff that worked there, particularly Andrew
Stevens and Nigel Brooks, who worked on the sheep projects. I remember the lunches
and Friday nights that were spent at the White Hart pub, which was in Headington, close
to the NIMR and Morris and Cynthia Jacobs, who ran the pub at that time. Most of the
scientific discussion that I had with other NIMR folks occurred in the White Hart pub.
There were also cricket matches, volleyball and other sporting events on the lawn in
front of the NIMR, at least until the John Radcliffe Hospital was built.
4. The common open lab that was at one end of the second floor of the NIMR. I know that
open labs are common now, but back then they were not. I had a bench in the lab, for my
AVP bioassays, and also in the lab were Barbara Johnston, Fiona, Eugenie and Joan
Mott and Richard Harding. We got to know a lot about each others’ research by being in
the same lab, although there were sometimes disadvantages. Barbara was working on
the effects of hydralazine on cardiovascular function in rabbits and did the experiments
right next to my bench. One day a carotid artery catheter came out and blood from the
rabbit spurted over me and some papers I was reading. I still have some of these papers
with spots of dried rabbit blood. Another time, a rat that I had in a cage escaped and
disappeared although there was some evidence that he was still in the lab. A month or so
later, the paper feed on the polygraph recorder that Richard was using stopped working.
Ken Bolton came up to look at it and found that the rat had made a nest in the recorder
using the polygraph paper for the nesting material. He blew it out with compressed [air]
not realizing that the rat was still in there.
5. The research infrastructure that was present in the NIMR, which included electronic and
mechanical shops, photography and histology services, with the latter overseen by
Majorie Prichard, who had worked with Barclay and Franklin, before Geoffrey became
Director. This made it possible to have specialized equipment and apparatus made
quickly in house and this definitely benefited me during my doctoral and post-doctoral
work. As much as the services provided, it was the characters that worked in the shops—
Harry Elvidge, Ken Bolton, Stan Ashington and others, that made it very interesting and
enjoyable. Ken was responsible for keeping the Schwarzer polygraph recorders working
and I still remember his repeated comment when the calibration procedures worked—
Perfectus Jubilatus. He has served in the British Army in India during the war and had
lots of Indian words that he used. Harry served in North Africa.
6. Another important resource was Derek Wyatt, a medical physicist who was one of the
NIMR faculty. He had developed the electromagnetic flowmeters that Geoffrey had used
in his early fetal cardiovascular studies and when I was there Derek was still working to
improve the flowmeters. I think they were the best flowmeters ever developed but I do
not think that they were ever commercialized. Derek also contributed to the design of
many of the other devices that were developed, particularly those used for fetal HRV
studies and the early work on computerized analysis of fetal breathing. I got to know
him quite well as we both worked at night and his lab was just around the corner from
the open lab. Every once and awhile he would come in and chat. Like most of the faculty
and staff in the NIMR, he had seen military service in the war—in his case as a midship-
man on the battleship King George V and would talk about his experiences, as well as
other more contemporary subjects, during these evening chats.
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 451

7. The weekly seminars that occurred in the NIMR. Sometimes they were given by outside
visitors but more often were presented by folks in the NIMR. In the latter case they were
more informal, involving discussion of current or plans for future research.
(Letter from DR to LDL, 22 December 2009)

Mark Hanson, (Fig. 20.1k and m) of the University of Southampton and who
worked at the Nuffield Institute during the 1980s, also recalled Dawes’ rigor,
Geoffrey of course could be a harsh critic, partly because he insisted on high standards in
science. He was not averse to poking fun at those whose results he thought were weak.
I remember a large clinical meeting in London where a young clinician was presenting
some blood gas results from cordocentesis samples. During the discussion after his paper it
appeared that he had not measured pH, nor did he seem to think that this was an important
consideration. Geoffrey rose to his feet and said that the paper, and the approach of the
young researcher, reminded him somewhat of a mistake recently made by his secretary in
typing a paper. The phrase she had meant to type was “buffer the pH”. However as on the
standard keyboard the g is next to the f it is very easy to make a mistake. So what she typed,
and what reminded Geoffrey of the young man’s approach …
But perhaps my favourite reminiscence of Geoffrey is a story which he told … against
himself, and to remind the audience of the importance of skill, patience and keeping a cool
head—qualities which he attributed to Mont Liggins in particular … Geoffrey and Mont
were keen fishermen and one day, somewhere in the world, were in a boat, on a lake, fishing
from the early hours of the morning (Fig. 20.1p). The day passed without either of them
catching anything, or even getting a single bite. When the evening drew on and they were
just about to give up Geoffrey saw in the distance the characteristic ripples of a fish rising.
In great excitement he leapt to his feet in the boat and shouted “Look Mont, look there’s a
fish!”. “I know Geoffrey” remarked Mont dryly, “it’s on the end of my line.”
(Letter from MAH to LDL, 12 March 2009)

From the University of Nottingham, Fiona Broughton-Pipkin who worked at the

Nuffield Institute in the early 1980s, has recalled some aspects of Dawes’
mentorship,
He was … very strong on everyone talking to everyone else at coffee- or tea-time, and that
is also an excellent training. Listening, arguing, asking for advice, picking up different
ideas, in an informal setting works very well, and it strengthened the team spirit among that
group of marked individuals.
One of the things I particularly remember about Geoffrey was his insistence that no-one
from [the Nuffield Institute] should read any presentation which they made at a research
meeting. This initially terrified me, but the point that, if you couldn’t talk about your own
work without notes, you didn’t know it very well, was entirely fair. Once I began to super-
vise my own students, I insisted on the same thing, and have continued to do so.
He probably didn’t realise that he inadvertently taught me something of man-management
too. One day I asked him if I could try a particular set of experiments, having, I thought care-
fully, explained why. He said “No”, with reasons which I wasn’t sure about. A few weeks later,
he said “You really ought to be thinking about looking at …” (the experiments I had wanted
to do). Being well brought-up, I bit my tongue, didn’t say “But I asked you about doing that a
couple of weeks ago”, and just got on with them. A little later much the same thing happened
again, and again I bit my tongue. I had, however, learned, and used the technique reasonably
successfully quite often thereafter. The gestation period was usually 2–3 weeks!
I remember with great gratitude an intervention from him at the very first external
research meeting at which I spoke, the Neonatal Society meeting in Newcastle upon Tyne.
They are a friendly Society, but one’s first meeting is something of a nightmare. The actual
presentation went reasonably well, though the long pointer in my hand was swaying like a
pendulum, but someone (I can’t remember who) asked a question which made no kind of
452 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

sense to me. I thought that I must have misheard, and asked for it to be repeated. Still no
understanding—but at that point Geoffrey twisted round in his seat and said something
along the lines of: “X—that’s not at all the area Fiona’s working in. We can talk about it
afterwards”. I could have hugged him!
(Letter from FB-P to LDL, 9 June 2009)

In March of 1981, Dawes was honored by the Queen, Elizabeth II, as Commander
of the Order of the British Empire (CBE) (Fig. 19.1a). Fiona Broughton-Pipkin recalls,
He was, as you may remember, given a CBE by the Queen. This is the highest of our civil
“British Empire” Orders other than a Knighthood. We were all delighted by it, and
Worcester College, of which he was a Fellow, threw a very good party for him. It was in the
Fellows’ garden, on a glorious summer evening (we do have them sometimes!), and was
very Oxford. (Letter from FB-P to LDL, 9 July 2009)

David Walker (Fig. 20.1f) of Monash University, Melbourne, Australia, also contrib-
uted some thoughts on Geoffrey Dawes and the Nuffield Institute during the 1980s.
What did we call him?
I think we all ended up calling him ‘GSD’, but I remember being surprised when I first got
to Oxford that many in the lab addressed him as ‘Sir’. Not Sir as in Sir Geoffrey, but Sir as
one would address a revered school master. As a naïve colonial boy I remember being rather
puzzled by this. Most of those calling him Sir were Canadians, and I wondered if this was
something they always did back home in relation to senior colleagues. It didn’t seem to
matter to Geoffrey—I don’t think it mattered particularly what you called him as long as
you weren’t rude or disrespectful. In my case I went some months (a year, perhaps) before
I felt comfortable in moving from ‘Dr. Dawes’ to Geoffrey. It was sometime after I came to
Oxford in 1974 that he officially became Professor Dawes.
Listening.
GSD was a quiet man and not someone who needed to proclaim his opinion at any oppor-
tunity. At times he seemed to be quite remote. Mostly, he was a good listener, and whenever
he said anything you listened carefully. Because he was so famous and we were all striving
to become known, it wasn’t unusual for someone to take the high ground in order to impress
him. This often took place at a round table in a common area at the top of the stairs in the
Nuffield Institute where everybody gathered for morning or afternoon tea—a quaint ritual
that has simply vanished. There was even a tea lady who made a big urn of tea in readiness,
and there were biscuits. People smoked, and GSD famously had a pipe with wonderfully
aromatic tobacco. Somebody would hold forth on something or other—it was almost
always to do with physiology or medicine, and rarely about politics even though the UK
was in turmoil at that time with fuel shortages and union strikes, and anyone could have
been forgiven for venting their spleen over the current situation. Anyway, Geoffrey always
did the speaker the courtesy of listening carefully. Often he looked quite inscrutable, and if
he said nothing or little in reply that was as good as letting you know you didn’t really know
what you were talking about. But when he did offer an opinion—and again it was rarely
about anything other than the work we were all trying to do—then you had to listen care-
fully because it was always important.
Fishing was another matter—he was always happy to talk about fishing.
Mentoring.
This is probably too modern a word to apply to Geoffrey. I don’t think he ever thought it
was his responsibility to ‘mentor’ any of us in a formal way, and I can imagine him ‘Hrrmp-
ing’ at the idea that you might need to be formally trained to do it, as is the fashion in uni-
versities today. His attitude was more like ‘jump in and learn to swim’, and I remember him
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 453

saying something like that about somebody, to the effect that he thought they were at risk
of drowning! I don’t remember ever receiving direct advice. But what I do remember is that
if you had made an observation and wanted to talk to him about it, he would always listen,
prompt again and again about the circumstances, ask you what you thought about it, what
did you know about the topic relevant to this, and slowly the excitement would build, and
then you had all his attention, and all his support, and all his knowledge.
Progress.
I don’t remember GSD ever calling a meeting specifically for everybody to report to him on
the progress of their work. Usually, the way it worked was that when you had a finding (was
it a real ‘discovery’, or not?) you would try to catch him during one of his peregrinations
through the Institute, or at morning or afternoon tea. When you were telling him what was
happening he became very still, and looked at you very quietly but intensely, and then he’d ask
you what you thought it meant. Now, this was difficult because you were always at the limit
of your knowledge, but after you had stumbled through some sort of explanation he would
then tell you what it probably meant, that someone else had published on this before and you
would be well advised to read it, but ‘Well done’ and, ‘Now, what are you going to do?’
Grant writing.
Somewhere in my files I have copy of a grant application that GSD submitted to the MRC.
This would have been about 1978, and it is only 3 or 4 pages in length. The copy I have is
probably the third or fourth carbon copy, because this just pre-dates the arrival of office
computers with word processors and was typed on an IBM golf-ball typewriter by GSD’s
secretary. It is a request for funding to continue work on fetal breathing movements, and
outlines in the simplest terms what he had already achieved, and why it was important to
continue this work. There are no graphs or figures or tables in this document, no detailed
research plan, costings, or mention of how the data would be analyzed, but it is utterly
convincing and most likely was successful because we continued this work for the next 5
years or so.
That is all I can say about how the activities of the Nuffield Institute were supported. It
is a mark of GSD’s organizational ability that we—the workers from many different places
in the world—never had to worry about the realities of research funding except at the per-
sonal level of ensuring that our salaries from our home countries were covered. When my
initial salary support from the Nuffield Dominions Scheme ran out, GSD provided me with
a MRC Research Fellowship and I continued not even having to worry about salary support
for several more years.
There was a ‘down side’ to all this of course, because reality hit home rather forcefully
a few years later when one really did have to find all your funds for research. But what I
want to say is that, while I don’t really know how the entire Institute was funded year in,
year out, for many of us we had several years not having to worry about this side of things
at all, and we were free to immerse ourselves wholly in the demands of research.
Seminars and conferences.
We were expected to participate in the Oxford meeting of the Physiological Society, and
with the advent of the FNPS we were all excited about being able to stand up and deliver
the new discoveries that we thought we had made (usually much less novel and complete
than initially imagined). Even with these exercises, which I expect were quite important to
GSD and the reputation of the Institute, there was virtually no pressure from GSD for
people to participate or perform. But if you wanted to, then he was very, very good at get-
ting you ready. He taught us how to speak slowly, to say one thing at a time, and emphasized
that the audience would totally forget what you had been staying unless you tried to leave
them with one (at most, two) important points to take home. It was probably at these times
that I had the most intimate contact with GSD—he taught and I learnt.
Fetal physiology—during and after GSD.
454 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

When I got to the Nuffield Institute in 1974, although Liggins had made an impact with fetal
breathing and fetal sleep, and Thorburn’s influence with fetal endocrinology was increasing,
the major legacy of GSD’s work on the fetal circulation and the placenta was still very
dominant. There was a palpable friction between GSD and Thorburn, and as an Australian
I think I was expected to fall into the Thorburn camp but I resisted this and placed myself
with GSD. I was still in the thrall of his book “Fetal and Neonatal Physiology” which I car-
ried everywhere and read constantly. I would have liked to work on primates and was hop-
ing that another trip to Puerto Rico might come up, but instead I was paired with Colin Jones
and asked to work on catecholamines. This was nearly a very great disaster because Colin
was a very poor teacher, I didn’t know anything about HPLC, and the equipment they had
was appalling and wouldn’t have been able to do the job. In the event I had to make myself
an expert in fetal surgery so that I could find the fetal adrenal gland (I had never seen one
before this!), and I am eternally grateful to Jeffrey Robinson and Knox Ritchie for their
patience and kindness. The work eventually went well and was done mainly by Barbara
Johnston and myself. We managed to adrenalectomies and devised a method for injecting
formalin into the middle of the adrenal to effectively produce a de-medullated gland. To this
day I have no idea where Colin got the catecholamines assayed, but they were not done at
the Institute. During all this time GSD was very interested and thought the work important,
but never sought to direct it—except of course, by somehow allowing it all to proceed with-
out us having to worry about where the funds were coming from.
Colin Jones brings me to thoughts about GSD’s possible successor. There was no
Deputy Director of the NIMR—at least, not that I knew about. I think Colin thought he
would be the next Director, but there was nothing GSD ever said or did that confirmed this
to me. Joan Mott and Heather Shelley never discussed the idea, but I remember John Bassett
proposing that Geoff Thorburn would eventually take over the Institute. I think Paul
Johnston, though very clever, was considered too erratic to be trusted with a directorship.
So—all the time I was there (1974–82) GSD was the director and there was never any seri-
ous common-room talk about what was going to happen next.
Then the story starting circulating about what GSD was supposed to have said to an
Oxford University committee, to the effect that when he retired everything of importance in
fetal physiology would have been achieved. I won’t say who put this about, or who said it
was true and an absolute fact, but it had a very destabilizing effect. This would have been
1980 or 1981, but I remember that Thorburn was already back in Australia so perhaps it is
the later date. There was a feeling that there wasn’t much future for the NIMR, and that with
the further development of the John Radcliffe hospital site there were many people who
wanted to see it go. Certainly, a great many people left after this time.
For the record, I don’t think GSD said anything like that. As remote and withdrawn as
he could sometimes be, and sometimes acidly critical of some of his peers with whom he
had to complete for MRC funds (for example, Robert Comline and Michael Purves would
never forgive him for apparently excluding them from MRC funding), he was not arrogant
to the point of believing that fetal physiology rested only on his shoulders. His 1968 book
is a testament to his academic generosity. I think he could well have said something like—
‘by the time I retire I will have achieved everything I set out to do’. He was very aware of
all the new developments taking place in molecular biology, and David Barker’s work was
known to him at this time. He had actively promoted all the work being done by Jeffrey
Robinson on fetal growth retardation, and he was vigorously pursuing the computer-aided
analysis of fetal heart rate monitoring. In short, he knew that greater collaboration with
clinicians was going to be very important. He may have recognized that the type of work to
be done in the near future would be different, and that there were significant forces at work
within Oxford University that would make it difficult for the NIMR to stay as it was.
Whatever it was going on in his mind at that time, it is perhaps typical that he didn’t discuss
it openly or draw the NIMR staff together to let them know what might happen in the near
future. I think the only person that might have been drawn into his confidence would have
been Jeffrey Robinson, but if memory serves me correctly he had also already departed to
Adelaide.
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 455

That is all I can remember in any detail. It doesn’t seem enough, but I can say that I have
no regrets about the time I spent in Oxford. Mark Twain [(1835–1910)] wrote (more cor-
rectly, dictated) an autobiography that he stipulated was not to be published until after his
death. At the end of the Preface (As From The Grave) he writes:
“It has seemed to me that I could be as frank and free and unembarrassed as a love let-
ter if I knew that what I was writing would be exposed to no eye until I was dead, and
unaware, and indifferent.”
Well, I’m not dead yet and I have written very few love letters in my life, but I came to
have a genuine love for Geoffrey and remain very much in his debt. I wish I had known him
better.
(Letter from DW to LDL, 30 January 2010)

Regarding Geoffrey Thorburn, the Nuffield Institute, and Dawes, Richard

Harding (Fig. 20.1i) of Monash University, Melbourne stated, “you may know
know that Geoff[rey] Thorburn was not healthy, in fact at times was seriously ill,
during his period in Oxford. However, he accomplished a lot in spite of this and in
spite of Dawes’ attempts to keep an “upstart Aussie” under control. There was quite
a bit of rivalry; both Dawes and Thorburn were similar personalities. Dawes was
apparently incensed when he found that Thorburn had been approached as Dawes’
successor after Dawes’ retirement” (Letter from RH to LDL, 1 March 2009).
Arne Jensen, (Fig. 20.1a) of the University of Bochum, worked at the Nuffield
Institute during the academic year 1983–1984. He has recalled,
Dawes attended the meeting on Fetal Heart Rate Monitoring—Clinical Practice and
Pathophysiology in Rauischholzhausen near Giessen, Germany, in summer 1983. He pre-
sented his data from chronically prepared fetal sheep on breathing movements that were
dissociated from the ECoG pattern after brainstem transection, demonstrating that higher
centres are responsible for the inhibition of fetal breathing during high voltage ECoG
activity. The other intriguing observation was that in normal fetal lambs a minor degree of
isocapnic hypoxia causes arrest of fetal breathing movements. This reflex is abolished
when the brainstem is sectioned in the upper pons. Then the fetuses are sent into continu-
ous breathing during isocapnic hypoxemia, an effect that is unrelated to chemoreceptor
activity, because the effect is still present when the carotid nerves have been cut. A pos-
sible explanation was, that section of the brainstem in the upper pons or above may dam-
age the blood supply to the medulla and hence to the respiratory centres residing there, so
that blood flow is unable to increase sufficiently to maintain normal metabolism in
hypoxia.
This point was raised by the reviewers when GSD submitted the paper for publication,
and the onus was on him to prove that local hypoxia due to the transaction-procedure—
hence an artefact—was not involved. This criticism was not easy to disprove in the absence
of a method to measure organ blood flow in distinct parts of the fetal brain.
[At] the same meeting on Fetal Heart Rate Monitoring our group presented data from
chronically prepared fetal sheep on circulatory changes during asphyxia and those in organ
blood flow—particularly to the brain—using the radioactively labelled microsphere tech-
nique. This method, adopted from … Rudolph and … Heymann, was modified by us to
observe dynamic changes in organ blood flow in a short period of time. After my talk GSD
approached me, … saying: “I believe, it wouldn’t do your career any harm, if you come to
Oxford, would it?” …and off he went. It almost took my breath realizing that the author of
the book Foetal and Neonatal Physiology, the bible of fetal physiologists, had just invited a
young investigator like me. I was thrilled.
By this time GSD knew already that I was bound to do my post-doc fellowship at the
CVRI at UCSF with … Rudolph, his great rival. His intention was clear, he wanted to get
456 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

hold of the microsphere technique, to prove the point that local hypoxia after brainstem
transaction was not the cause of continuous breathing during hypoxia, rather the disrup-
tion of the neural pathway that blocks fetal breathing in the normal fetus when oxygen is
at short supply. And—beyond this scientific reason—he loved the idea to ‘snatch’ me on
my way over to San Francisco before I would leave in summer 1984 to work with …
Rudolph. Thus, to my knowledge, I had the unique privilege to work with both protago-
nists… I was very proud to be invited and overwhelmed by the scent of academic life in
Oxford. I had such great pleasure in imagining being part of it, that I intended to undertake
a degree at Oxford University, but GSD talked me out of that, saying: “Arne, I have seen
so many people ‘dripping from degrees’. Don’t be overly impressed—they never get
things done”.
It became quite clear during the visit that for GSD it was a matter of utmost importance
to make the point that after brainstem transaction the functional integrity of the spinal
medulla below pons was unambiguously proven to support his theory. Hence, my main task
for my stay in the Department was to establish the microsphere technique, validate and use
it in a study on the effects of brainstem transaction and on isocapnic hypoxemia. To provide
a personal project for myself, a study on fetal organ blood flow changes during high and low
voltage ECoG activity in normoxia and during hypoxemia was designed …
Being a clinician amongst basic scientists was a heavy burden, particularly since I had
to set up a fairly complex new method. Even more scepticism arose, when it became obvi-
ous that the historic Packard Gamma-Counter that had not been in use for ages required
major repair, because the crystal had a crack and produced erratic count rates during the
standardization procedure in various parts of the spectrum. Raised eyebrows followed the
service bill of 26,000—Pounds Sterling, including a replacement of the crystal, but GSD
defended the project even though not a single measurement was accomplished as yet. In the
meantime GSD set out to write the programme in Basic on his own computer, me sitting
aside of him in his study, trying to explain the algorithm laid out in formulae that were fairly
complex. We chose to use five different isotopes. Hence, the spill-over from one spectrum
into the next affected the count rate and had to be mathematically accounted for. … GSD
was not amused, pulled his hair and bluffed: “What the flaming hell are you trying to tell
me, Arne. Would you mind stopping confusing me, please!” But in the end after 4 weeks of
programming and eliminating computational bugs he was delighted. “Congratulations,
Arne, we’ve got it done!” This joy was even topped when after six weeks the first real organ
blood flow results came out of the printer. He took the print out, two meters in length, and
waved it through the air going from one laboratory to the other to present the success. He
obviously was relieved that the unexpected enormous hardware investment … in a junior
German clinician had eventually paid off.
Being a novice in scientific writing my manuscripts were lengthy, extremely verbose,
redundant, and unclear for uninitiated readers. This evoked GSD’s pity. Obviously in reward
for my engagement in setting up the microsphere method, he offered his editorial help and
sat down with me to streamline my manuscripts word by word, jotting down his corrections
with his distinct handwriting in pencil. He was a purist and, among other things, hated
poorly defined expressions in written or spoken English, e.g. STRESS.
GSD’s manuscripts were pieces of art in scientific writing and subjected to scrutiny
before submission for publication. I once was heavily criticized in a typed letter for submit-
ting a manuscript in a ‘pre-final’ version and he added the following post scriptum written
by hand: “I hope you will not feel too hard about this letter. Ultimately what you, and I, are
judged on is not speed but accuracy, care, excellence.” This paternal and personal tutorship
of GSD was the most enlightening and fruitful experience in my scientific career, which
made me utmost grateful.
One of the most impressive personal experiences was when we were invited to his home
at Belbroughton Rd. 8 for a round of Croquet followed by dinner. There we came to realize
that GSD besides being a world renowned scientist and Director of the Nuffield Institute,
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 457

also took a lot of domestic responsibilities, as his dear wife Margaret was blind. This was
the most memorable afternoon. He introduced us to the art of rose gardening—his favorite
hobby besides flyfishing.
(Letter from AJ to LDL, 15 April 2009)

In regards to Dawes’ administrative style, several correspondents commented

upon his total dedication, with single-minded focus on the task at hand. Pierre Foex,
at that time on the Governing Body of Worcester College, recalled that during a
discussion of academic visitors, and the work entailed in their being hosted, Dawes
noted that “… with visiting scientists, there is a strict rule: one day or one year,
nothing in between!” (Letter from PF to LDL, 3 November, 2009).
Nonetheless, Dawes was not always focused, and could be rather aloof from his
surroundings. From a visit to Auckland in the early 1980s, Ross Howie recalled,
I remember meeting him only once personally, and then briefly, when Mont Liggins brought
him into our neonatal unit … I had looked forward to meeting Dawes—there was so much
I thought we could have talked about—but he gave me the impression that could have been
the first time he had visited a neonatal unit anywhere. He was a great physiologist but
seemed not much interested in the clinical applications of his work. In Oxford the heads of
both pediatrics and O&G (Tizard and Stallworthy) were friends of mine but there seemed to
be very little interaction between their departments. That could have applied to physiology
as well. Having been used to good collaboration in Auckland that came as a surprise to me.
(Letter from RH to LDL, 3 December 2011)

From the Oregon Health Sciences University, Portland, Kent Lu Roy Thornburg
(Fig. 20.1g) recalled,
I met Geoffrey Dawes when he came to Portland in the early 70s. I had used his 1968 mono-
graph as a textbook for a fetal physiology course in my graduate program a few years ear-
lier. I was anxious to meet him. During our visit, he became intrigued with our data on the
electrical potential in the placenta, and invited me to present the work at the Physiological
Society meetings in Cambridge. He took me under his wing and allowed me to stay in his
home. I also stayed for a short time with Richard Harding who was in the Dawes laboratory
at the time. I remember one warm evening when we sat in Geoffrey’s back garden, he
offered milk to a hedgehog with whom he had evidently developed a long-term relation-
ship. Geoffrey made kissing sounds to entice the little creature to the milk saucer.
Geoffrey supported my work. He was especially happy when we countered the view he
expressed in his book that the two fetal ventricles are alike. I was worried that he would be
upset with our findings. He was at the meeting on Vancouver Island when I gave a paper on
the topic. I remember saying that unlike the words in the fetal bible written by Professor
Dawes which side with William Harvey by saying that the fetal heart ventricles are “… of
much the same shape and size, like the twin kernels of a nut …” (Dawes 1968), the ventri-
cles are actually very different in shape, size and function. During the discussion period that
followed, he walked to the microphone and jokingly made the comment that from time to
time the “Fetal Bible” has to be revised. He took no offense. At a later time, however, he
suggested that I should not try to publish one of our papers on fetal lung function in the
Journal of Physiology because it contradicted work that he had previously published in that
journal. He thought it would be confusing to the reader. More to the point, I think he was
convinced that our data would stand the test of time.
Geoffrey and I corresponded from the time we first met, and I visited him from time to
time thereafter. In 1989, he invited me to participate in a meeting on fetal physiology in
Liguria. He offered an enticing note by saying that he wanted to introduce me to a David
Barker who “… has gathered evidence which suggests that defective perinatal growth may
458 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

be associated in adult life with the liability to hypertension and ischaemic heart disease…”
(from Dawes 1990, p. 4). The proceedings of the meeting became a monograph. David
Barker and I solidified our friendship at that meeting and we have from that time forward
been soul mates in our quest for understanding the fetal origins of adult disease. We are
grateful to Geoffrey for bringing us together.
(Letter from KLT to LDL, 3 May 2010)

As editor for many years of the journal Obstetrics and Gynecology published by
the ACOG, Roy Macbeth Pitkin, Emeritus Professor at the University of California
Los Angeles, recalls Dawes’ contributions as a reviewer of manuscripts.
His reviews were always detailed, objective, and in all other ways perfect. Additionally,
they always came back very promptly. The last I sent was returned by his wife with a note
saying Geoffrey had died suddenly (a stroke, as I recall) several weeks earlier. She added
her thanks for my sending papers for him to review, saying it had meant a great deal to him
to be asked to perform such academic duties. What a scholar!
(Letter from RMP to LDL, 7 January 2010)
Several correspondents emphasized the role Joan Mott played in Dawes’ studies,
in essence being his “girl Friday.” Although she was capable and clever in designing
original approaches for their joint studies, yet she remained “underappreciated” for
her abilities and intellect. One correspondent stated that, although Mott worked
independently in her studies of the role of the renin-angiotensin system and the
regulation of blood pressure in the developing mammal (Mott 1978), for the most
part, her role was that of a high class technician as Dawes’ “spear-carrier.” In his
obituary of Mott, Dawes barely refers to her role as a Nuffield Institute fellow sci-
entist and collaborator (Dawes 1994).
In preparing this review, I contacted almost one hundred individuals who either
worked with, or were contemporaries of Dawes. Somewhat surprisingly to me
were the number (over a dozen) who expressed reservations or overt hostility, to
the extent that they declined to comment, or stated frankly that they did not wish
to contribute in any manner. As noted, Dawes had his “rough side.” Early on, he
disagreed with the statutes of the Nuffield Institute, and had some conflict with
Gordon Ardran concerning the importance of radiologic studies. Among those
who would discuss Dawes or their relationship with him, the major reservations
regarded his at times self aggrandizement, rather authoritarian management style,
frequent failure to acknowledge other contributors to a given field, often marmo-
real aloofness, offering of animadversions, and on rare occasion overt hostility and
argumentativeness. Several stated that he ran the Institute in a most “paternalistic”
and “authoritative” manner. Apparently, staff meetings were seldom held, there
often was disagreement and conflict at those Institute meetings that were held, the
committee minutes were kept secret, and he had no tolerance for what he per-
ceived as insubordination. One individual stated that, he could be the “Genghis
Khan” of British developmental physiology, who fostered a “cult” following
among those working, or who had worked, at the Institute. Another wrote of him
as an éminence grise [grey eminence, powerful advisor], mentioning “… the inse-
curity in which he found himself as the nominated pioneer of a field he was not
really able to master.” Liggins has referred to some of these issues (Liggins 1998,
pp. 114–116).
20 Dawes as a Mentor: Reminisces of Former Graduate Students… 459

As noted, although quite supportive of young people and their work, Dawes
could be cool or even hostile to anything that smacked of mediocrity or careless-
ness. From the mid-1960s onward, I participated with Dawes in about two dozen
international meetings of various types. On several occasions was I taken aback as
he engaged in hostile and bitter debate with individuals with whom he differed.
As I understood the conflict, it was because the individual with whom he had a dif-
ference of opinion was somewhat glib, careless, or cavalier in his presentation, or
their findings contradicted his own work. Also on two of these occasions, the
confrontations precipitated a severe attack of status asthmaticus. These experiences
left in his wake a train of considerable angst. Among respondents to my queries,
several stated that Dawes was a “complicated person,” and despite them having
worked with him at the NIMR, they never became truly well acquainted. Others
were downright negative.
Dawes’ son, Nicholas William recalled his father’s interest in people as well as
science.
He would stop and make time to listen to the difficulties of running a small fishing shop in
rural Ireland or the problems of a carpenter in getting hardwood for making furniture. It was
the knowledge that people shared with him that he found fascinating. Their expertise and
experience in widely varying backgrounds was always of interest. He would take as much
delight and pride in understanding, and practicing, the mechanics of smoking fish as he
would the variability of fetal heart rate. He smoked his own Adwell-caught trout, with
sawdust he bought from the local arboretum. It was delicious.
(Letter from NWD to LDL, 18 January 2009)

Nicholas also reminisced about his father’s plans for the future.
Pa always had long term plans. Even in January 1996 he had a five-year rolling plan and
would explain it with great energy. This was one of the reasons for his extraordinary success
at research, since the short term held for him the steps needed to move towards the long
term goal. Even the choice of five years as a horizon had been carefully thought out.
(Letter from NWD to LDL, 18 January 2009)

In regards to any successful group, the question arises, what are the major factors
that account for their achievement? In the social sciences, the concept of “network
theory” is that individuals become imbedded in webs of social interactions and rela-
tions to succeed and endure. That is, the theory attempts to explain a myriad of
social phenomena, from the creativity of an individual or group to the profitability
of a corporation (Newman et al. 2006). Applied network analysis, with determina-
tion of the “social fabric” or degree of “centralization” versus “decentralization” of
structure and interrelations, is believed to account for the topology of ties, and the
extent to which power and influence determine a given outcome (Borgatti et al.
2009). In the case of the Nuffield Institute group, many would agree that a “central-
ized” mode would describe best its operation, with Dawes as the “sun” in a solar
system of talent. As noted, of former Institute members, a number recall with affec-
tion tea time and the stimulus of sitting around the large circular antique table at the
entrance to the Observatory. Here they would discuss and debate critical issues for
research (Also see Robinson 1997). With his commitment to clinical relevance,
Dawes was one of the founders of the “Neonatal Society of the United Kingdom”.
With the literal diaspora that occurred of bright young investigators in both basic
460 20 Dawes as a Mentor: Reminisces of Former Graduate Students…

science and clinical translational research, the influence of the Institute has extended
far beyond the UK to the USA, Canada, the European Continent, Australia, New
Zealand, and the World.
In the memorial service held for Geoffrey S. Dawes on 19 July 1996 at the
University Church of Saint Mary’s, his long-time friend and collaborator Christopher
W. Redman observed,
And what was the essence of the man?
He was strong-willed; some might have called him stubborn. There was a streak of
ruthlessness within him. He rarely failed to finish a project that he had started, and had the
ability to hussle things along if they began to lose their momentum. Here his phenomenal
reserves of energy—physical and mental—his toughness and resilience, were essential. For
a man qualified to practice medicine he was unusual in his mathematical skills; where most
clinicians flounder out of their depths he reveled in the precision of numeric analysis. His
logic was that of the chess player; he moved forward in methodical stages. He took a posi-
tion after careful appraisal of its validity and strength, then did not look back; his thinking
had a forward momentum with an end-game always in mind.
Was he a humble man? Well yes and no. He never lacked in self esteem but was not vain.
He had a straight forward estimate of his worth and saw no reason to hide it but neither did
he call attention to it. As important, he was always quick to appreciate the worth of others
and was generous in his praise of their achievements.
Was he a tolerant man? Well yes and no. He saw good in all those who, as was he, were
honest, rigorous and careful in what they did. But thoughtless modishness, careless or
sloppy thinking he could not abide and quickly said so.
His strong will was allied to a strength and vigour of mind that made him such a suc-
cessful man. But he was totally without deviousness. Which did not necessarily make him
always an easy colleague because he knew what he wanted and could be single-minded in
its pursuit…
So no longer will there come a light tap at my office door. And no longer will he appear
with his pale blue eyes twinkling above half moon spectacles, below a shock of thick white
hair, slightly hunched but nimble even in his late seventies, to slip into my room with the
announcement: “May I disturb you. I have something absolutely fascinating to tell you.”
And it was true; he always did, some interesting further development in his thinking or
analysis to reveal for discussion. He delighted in discovery, logically made, rigorously
tested and proven to be robust. He made discovery exciting; our discussions were punctu-
ated with explosions of his laughter, long peals of mirth marking pleasure in some humor-
ous aspect that could always be shared. He would hunch his shoulders, rub his hands
happily and gleefully chuckle “Isn’t this fun!”
(Redman 1996a)

In a later obituary notice, Redman recalled Dawes’ love for, and commitment to
his wife Margaret and his two sons and two daughters. Redman concluded, “Of
formidable intellect, great integrity and questioning spirit, he was also a kind and
humorous man” (Redman 1996b, p. 18).

References

Borgatti SP, Mehra A, Brass DJ, Labianca G (2009) Network analysis in the social sciences.
Science 323:892–895
Dawes GS (1968) Foetal and neonatal physiology; a comparative study of the changes at birth.
Year Book Medical Publishers, Chicago
References 461

Dawes GS (1990) Fetal autonomy and adaptation. In: Dawes GS, Borruto F, Zacutti A, Zacutti A
Jr (eds) Fetal autonomy and adaptation. Wiley, Chichester, pp 1–4
Dawes GS (1994) Obituary: Joan Mott. The Independent 6 May
Liggins GC (1998) Geoffrey Sharman Dawes, C.B.E. 21 January 1918–6 May 1996, Elected
F.R.S. 1971. Biogr Mem Fellows R Soc 44:111–125
Mott JC (1978) The fetal renin-angiotensin system. In: Longo LD, Reneau DD (eds) Fetal and
newborn cardiovascular physiology, vol 1. Garland STPM Press, New York, pp 415–438
Newman A, Barabasi A, Watts DJ (eds) (2006) The structure and dynamics of networks. Princeton
University Press, Princeton, NJ
Redman CWG (1996a) An address given … in the University Church of St. Mary’s, Oxford at the
Memorial Service for Professor Geoffrey Sharman Dawes on July 19, 1996
Redman CWG (1996b) Obituaries/Gazette. Professor Geoffrey Dawes. The Independent. 16 May,
p. 18
Robinson JS (1997) Obituary. Geoffrey Sharman Dawes 1918–1996. Placenta 18:89–90
Chapter 21
Early Years of the Society for Gynecologic
Investigation, the Fetal and Neonatal
Physiological Society, and Several Other
Groups

Until the mid-twentieth century, academicians in obstetrics and gynecology

concentrated their study primarily on the treatment of women’s reproductive mala-
dies and pregnancy. It is difficult to conceive of how elementary and empirical the
craft was, even these few years ago. Despite the responsibility for care of the fetus as
well as the pregnant mother, there was little interest in the basic biology of reproduc-
tion. Since that time, however, the specialty has matured as an academic discipline,
joining departments of medicine, pediatrics, surgery, and others as a field making a
serious commitment to both basic and clinical investigation of problems in its
purview. By increasing the understanding of normal reproductive function and its
regulation at the cellular and molecular levels, advancing the technology for diagno-
sis and treatment, and developing new approaches to therapy, academic obstetricians
and gynecologists have dedicated themselves to the improvement of health care of
women and their infants. In concert with clinical investigation, basic research has
increased enormously our understanding of the regulation and interrelations of the
maternal–placental–fetal complex, and the relations of these functions to optimiza-
tion of the course of pregnancy and to the life and health of the newborn infant.

21.1 Beginnings of the Society for Gynecologic Investigation

In the USA, to a great extent investigators on the cutting edge of these developments
have been members of the Society for Gynecologic Investigation, whose motto is
“science in the service of women’s health.” Founded in 1953 by a handful of
American academic obstetrician-gynecologists interested in “Toxemia of
Pregnancy” (preeclampsia and eclampsia), from initial studies of blood pressure,
renal function, and water balance in the pregnant women, the Society has grown to
a membership of about 1,000, a third of whom are basic scientists. Rather than rep-
resenting scientists from the USA alone, the Society has become international in
scope, including many investigators from Canada, the UK, Europe, Australia, and

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 463
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_21, © American Physiological Society 2013
464 21 Early Years of the Society for Gynecologic Investigation…

New Zealand, and the Far East. Although including reproductive scientists of all
varieties, a large contingent of the membership are fetal and neonatal physiologists.
From its simple beginnings, the Society has grown into a group of the world’s lead-
ers in the basic biology and clinical investigation in essentially all aspects of research
that relates to women. Currently in the modern era of molecular medicine, studies
conducted by the members rely heavily on cloning, exploring gene regulation, the
use of transgenic animals, tentative excursions into gene therapy, and related tech-
nologies of a brave new world of reproductive science. With the dawn of a new
century and millennium, members of the Society have striven to keep pace with the
rapid advances taking place in biotechnology, information technology, and an ever
enlarging global scientific community. Of importance to academic medicine,
Society members have contributed greatly to the building and development of cen-
ters of excellence in many of the University based departments of obstetrics and
gynecology and pediatrics, as well as to departments of physiology, biochemistry,
cell biology, and others. In turn, individuals in these centers of research ferment
have contributed greatly to the life of the Society.
Founders of the Society noted that it was organized “… to stimulate, encourage,
assist, and conduct fundamental gynecologic research and to provide opportunities
for investigators … to enter into free exchange of ideas to the end of increasing
knowledge and techniques in this field.” It was intended primarily for those indi-
viduals who were essentially full-time in teaching and research. Nicholas S. Assali,
of the University of California Los Angeles, cofounder of the Society and its third
president has written,
I saw it as a dynamic young society – and one that would remain so – where a presentation
could be thoroughly discussed and dissected. Such an organization would serve as a forum
to educate the young researcher and show him not only the good points of his data but also
the deficiencies.
(Assali 1979, p. 148)

It was the intention of the founders to keep the Society limited in size and youth-
ful, as one member observed “… if the free-for-all discussion … is to be maintained
the group will have to be kept small, certainly under 100 and ideally under 50. Then
everyone will be well enough acquainted to speak freely and ask for suggestions on
contemplated or unfinished projects” (Longo 1983, p. 34). Within the first 5 years,
the membership had almost quadrupled, within a decade there were about 100
members, and within two decades almost 200.
In the Society’s original Constitution, the status of members was defined to keep
the group young and vigorous.
Each member of the Society shall, upon reaching his fifty-fifth (55th) birthday, automati-
cally become an Emeritus Member of the Society. Emeritus Members shall be entitled to all
of the rights and privileges of other members of the Society, except that they shall not be
entitled to vote at any regular or special meeting of Members, nor to hold any elective or
appointive office in the Society. Each Emeritus Member shall, upon reaching his sixty-fifth
(65th) birthday, automatically become an Honorary Member.
(Longo 1983, p. 39)
21.2 Journal of Gynecologic Investigation/Reproductive Sciences 465

As has been noted elsewhere, several members of the Society played a critical
role in the 1962 founding of the NICHD, meeting with the then Director of the NIH
James Shannon and members of Congress (Longo 1983, p. 47ff).

21.2 Journal of Gynecologic Investigation/Reproductive

Sciences

In 1955, the SGI Council first considered the publication of an official journal for
the Society; however, little came of that suggestion. Nonetheless, with continued
agitation for a journal of its own, almost a decade and a half later (1969), Walter L.
Herrmann (1922–2012), then at the University of Washington reported to Council
that he had been in contact with S. Karger A.G., Basel, Switzerland, regarding a
journal to be entitled Gynecologic Investigation. This would replace Gynecologia,
a clinically oriented publication, and would serve as the official organ of the
Society. Following approval by Council, and the members at the Spring 1970
meeting, Gynecologic Investigation became the Society’s official publication
(Longo 1983, p. 54).
Although Volume 1, Number 1 of Gynecologic Investigation carried a 1970 date,
it did not appear until the following year. In this inaugural issue, the editor Herrmann
asked a critical question and reflected upon the literature in the specialty. Because
this editorial addresses ageless issues, it is reproduced below.
Who Needs a New Journal?
Discovering this latest addition to the already diverse array of gynecological journals
may very well prompt the compulsive consumer of professional literary offerings to sigh,
asking “who needs it?” – and move up to a large size waste basket. It is estimated that a new
medical article is published every 26 seconds in the world literature. This would mean that
in every 24-hour period an additional 3323 articles go into print. Fortunately, only a portion
of these articles relate to obstetrics and gynecology. Nevertheless, a significant number of
publications dealing with data of interest to the obstetrician are currently available, and this
editor admits, along with many of his colleagues, that his hope of perusing and assimilating
the material is usually greater than actual accomplishment. Furthermore, an admittedly
cynical attempt to prove that (paraphrasing the N.Y. Times) not all the news fit to print is
news, revealed some rather amusing facts. During the past 5 years there have been at least
78 published articles on Clomid, 542 on pregnancy tests, 543 on estriol, and 1228 on oral
contraceptives. During the first 3 months of this year, 96 articles on oral contraceptives have
already been published.
These facts alone perhaps would have discouraged us from the ambitious plan of remod-
eling Gynecologia, the Methuselah (1895) of gynecological literature with its modest circu-
lation, into a first-rate gynecological journal. Some searching and introspection are required
to justify this undertaking. With all due respect for the clinical practice of our specialty and
the usefulness of statistical clinical studies, case reports, applied pharmacology, etc., we
must recognize, along with other specialties, that experimentation in the basic sciences
provides the key to progress. At the risk of being redundant, let me say that investigative
aspects of medical science cannot be accepted as being “way over the head” of practicing
physicians and particularly not for the physicians in residency training. But such an objec-
tive requires a recognizable forum for dissemination, for discussion and for criticism.
466 21 Early Years of the Society for Gynecologic Investigation…

No such forum identified with Ob-Gyn is available at this time. Our scientists tend to
publish the results of their better efforts in sub-specialty journals, inviting the challenge of
highly discriminating, sophisticated, and rigorous editorial reviews, all for good reason: far
more academic credit is given by peers, prestigious societies, and promotion committees for
a paper published in the Journal of Clinical Investigation than one appearing in our more
clinically oriented periodicals. Having had some papers accepted and others turned down
by a variety of editorial boards, I can assure the uninitiated that there is a significant differ-
ence, with some of the following consequences: scientifically speaking, obstetricians and
gynecologists are seldom recognized on equal footing with colleagues of some other clini-
cal specialties; our residents too often shy away from reading anything that does not have
the “practical” appeal; gynecologists loyally restricting their reading time to “their” jour-
nals are not aware of the contributions of their most distinguished colleagues. Surely there
is the throw-away, the condensed, simplified, in plain-language communication for those
who prefer a medical Reader’s Digest instead of digesting and evaluating an original paper.
Such “shorties” merely allow one to remember the name of the author and his conclusions.
Whether such conclusions will hold water under the rigorous scrutiny of editorial review in
the strict scientific tradition, or better, whether the data and analysis will meet your own
criteria of validity, cannot be evaluated.
There is still another story. Curriculum revision in many schools has left Ob-Gyn largely
as elective material. The interpretation of “Core” material (obstetrics for non-obstetricians)
has reduced the educative process to one not too far removed of one befitting a trade school.
Here, too, identify of the specialty as a predominately scientific discipline is needed.
By the way, who in your school knows about the Society for Gynecologic Investigation?
And where is there a uniform source of material for study for the resident preparing himself
for the in-service examinations now being contemplated or for a better, more logical prepa-
ration for the Boards?
For an answer to the foregoing, admittedly with a fair dose of optimism – here is the
proposition for the Journal of Gynecologic Investigation: scientific reports in reproductive
biology, and related sciences. To be published in English only, we nevertheless plan for it to
be an international journal, with an editorial board providing a true peer review and criti-
cism, acceptance, or rejection of submitted material, to be determined by at least two refer-
ees and one of the editors.
Finally, for those who after all this still object to a new journal: in the spirit of the gen-
eral concern with the population increase, before starting this one, we have buried another.
We have only replaced ourselves.
(Herrmann 1970, pp. 1–3)

The first volume of Gynecologic Investigation published 25 papers, 23 of them

from SGI members. However, during the following years the number of manu-
scripts published per volume varied widely, and despite the editors’ prodigious
efforts, relations between the Society and the journal never went very well. Some of
this discontent resulted from transatlantic delays in receipt of the bimonthly issues,
ever increasing subscription costs, and delayed publication. In retrospect, much of
the dissatisfaction on the part of the members is difficult to define however. In the
autumn of 1975, editor Herrmann notified the Society’s Publications Committee of
his intended resignation, and this was accepted at the Interim Council Meeting.
Following this, the editors of the American Journal of Obstetrics and Gynecology
agreed that two issues of that journal, to appear at 6 month intervals, would be
devoted to SGI papers and that the manuscripts would be rigorously reviewed by the
editorial advisory staff. Daniel Randolph Mishell, Jr., of the University of Southern
California, became chairman of the SGI Editorial Advisory Committee, and the first
SGI issue of the American Journal of Obstetrics and Gynecology appeared 15 May
21.2 Journal of Gynecologic Investigation/Reproductive Sciences 467

1979 (Volume 133, Number 6) (Longo 1983, p. 54ff). Commencing in 1986, the
Journal changed its publication cycle from two to one issue per month, with one of
the monthly issues devoted to papers from Society members. Also at that time,
Rogerio Arnaldo Lobo assumed responsibility for editing the SGI issue of the
American Journal of Obstetrics and Gynecology.
Despite the efforts of editors, the years of this collaboration saw disagreements
over the number of pages/issues devoted to Society papers, perceived delays in pub-
lication, a requirement that Journal subscriptions be mandatory for all Society
members, and so forth. In 1988, the President Daniel Mishell appointed a commit-
tee to explore the feasibility of establishing a new and official Society journal. At
the March 1989 Business Meeting, Frederick Naftolin presented his committee
report. He noted that several issues justified the Society taking such action.
1) The Society members need to publish their scholarly contributions more rapidly; 2) The
Journal would enable the SGI to better fulfill its role as a flagship society representing the
best of scholarship in the reproductive sciences. This point was believed to be critical as
subspecialization in clinical and basic disciplines fragments research in reproduction and
the recognition of health care for women as a discipline; 3) The JSGI would serve as an
important public forum for the Society to express its point of view in academic and public
debates; 4) The JSGI could be an important source of income for the SGI; 5) By allowing
publication of non-members’ papers introduced by SGI members, the JSGI would foster
interest in reproductive research throughout the national and international scientific com-
munity; 6) The JSGI would serve as a timely site of publication for the high quality studies
presented at the Annual Meeting; and 7) The JSGI, as a publication of the stature of the
Journal of Clinical Investigation, would serve as an important yardstick of peer review for
academic appointments and promotions.

Thus, at that 1989 meeting following almost four decades of hesitation, debates,
discussion, and poll taking, the members finally voted to have their own journal. In
January 1994, almost two decades following the cessation of Gynecologic
Investigation (and during most of which time papers from the Annual Meetings
appeared in the American Journal of Obstetrics and Gynecology), the Journal of the
Society for Gynecologic Investigation first appeared, published by Elsevier Science
Inc (Longo 2000, p. S90).
In his celebratory essay “A Journal at Last!” in the inaugural issue, January 1994,
Nicholas Assali, effused,
…this decision is wise for the following reasons: 1) It definitely transforms the organization
into “a year-round Society”; 2) it provides the membership, particularly the young, with an
opportunity to read and examine some of the full papers that had been presented in abstracts,
the experimental techniques of which have great teaching value; 3) it permits the Society to
publish pertinent announcements and other matters of interest to the membership; and 4) it
liberates the Society from arbitrary decisions taken by other publishing companies …

Assali concluded,
For the membership at large and nonmembers who are interested in the field of reproduc-
tion, their obligation consists of providing maximum economic, scientific, and moral sup-
port. This support is badly needed during the early part of the Journal’s life. In addition,
patience and understanding are essential from authors who submit manuscripts to be con-
sidered for publication … May I wish you all good luck.
(Assali 1994, p. 2)
468 21 Early Years of the Society for Gynecologic Investigation…

In this premier issue, Editor-in-Chief Rogerio Lobo set forth the new journal’s
purpose and mission.
The JSGI provides an opportunity to bring the field together by publishing seminal papers
in reproductive biology. In so doing, the Society hopes that JSGI will become a primary
resource in academic medicine, reproductive biology, and obstetrics and gynecology in
particular.
The mission of JSGI is to publish cutting-edge research in all aspects of reproductive
biology. This will primarily be from papers presented at our Annual Meetings, but is not
limited to this forum. Other quality papers from members and nonmembers will also be
published. It is also our intention to publish important review papers in reproductive biology
as well as occasional editorials and position papers. In our first year we will publish quar-
terly, and the number of volumes will increase in the years that follow. (Lobo 1994, p. 1)

In comparison with several of the other major specialties (internal medicine,

pediatrics, surgery, and others), historically both basic and clinical research in
obstetrics and gynecology has been deficient. This is evident in terms of NIH-
funded grants for both research and training (Longo 1992). In an effort to correct
this deficiency, in 1988 the Reproductive Scientist Development Program (RSDP)
was initiated as a joint venture of the NIH and several professional societies in the
specialty. The goal of this program was to support young obstetrician gynecologists
for 2–3 years of basic science education in cell and molecular biology, working
under a world-class scientific mentor. This training, followed by a 3 year period of
establishing their laboratory and research program in one of the departments of
obstetrics and gynecology, would help to prepare them for a career in academic
medicine. In the mid-1990s, the Society elected to provide limited financial support
for the visionary Reproductive Scientist Development Program, thus matching
funding for NIH post-residency/fellowship education for obstetrician-gynecologists
in the basic sciences as related to reproductive medicine (Longo 1983, p. 54).
In an editorial, Frederick Naftolin and Tamas Horvath pointed out the role of the
new journal in “Providing a ‘Noah’s Ark’ for Research in the Reproductive Sciences
by Fostering Young Investigators: A Role for Our Journal.” They wrote.
For the past decade, the Society for Gynecologic Investigation has focused increasingly
upon the development of young investigators in the reproductive sciences. The JSGI should
do the same. We can identify those manuscripts whose authors performed their work under
the support of young investigator programs, such as foundation fellowships, the
Reproductive Scientist Development Program, the Clinical Investigator Development
Award, and the National Institutes of Health First Award (R29) Program. We can develop a
Young Investigators’ Forum. We can serve as a clearinghouse for professional opportunities
and support mechanisms. We can debate in print, and thus help develop the future structure
of research and funding strategies in our discipline. There is much that can be done to
stimulate research in the reproductive sciences until the rising tide of adversity recedes.

Naftolin and Horvath concluded:

Now is the time to foster the young investigator and encourage progress and excellence in
the reproductive sciences. We are privileged to have vehicles such as JSGI and the Society
for Gynecologic Investigation to use in carrying this mission forward. Let us use them to
their full extent.
(Naftolin and Horvath 1994, p. 246)
21.2 Journal of Gynecologic Investigation/Reproductive Sciences 469

Unfortunately, because of limited funds, this support for the RSDP lasted only a
decade. In addition, with the assumption of Hugh Smith Taylor of Yale University
as editor in January 2007, the name of the Journal was changed to Reproductive
Sciences.
In conclusion, the Society for Gynecologic Investigation was conceived through
the enthusiasm, drive, and sense of mission of a handful of investigative-minded
clinicians and several basic scientists. In the main, they were associated with univer-
sity departments of obstetrics and gynecology in the American Midwest. Their
explorations of the “frontiers” of the specialty initially focused on the hypertensive
disorders of pregnancy and rudimentary questions in reproductive endocrinology.
To that end, beginning in 1953, each year this coterie of “Young Turks” spent a day
gathered around a table presenting their work in progress. Over the past half-century,
the Society has evolved into a premier group of the leaders in the science of repro-
duction, growing into an international membership of basic scientists, physician-
scientists, and clinical investigators from many disciplines. To my mind, the Society
has developed and maintained a “Heritage of Excellence” in the reproductive sci-
ences. Maintaining this heritage, the assemblage now numbers almost a thousand
respected research workers who gather to present sophisticated, relatively complete
work on the cutting edge of biomedical science. A significant proportion of these
studies of “science in the service of women’s health” concern fetal and neonatal
physiology.
Several other societies have worked to advance the field of fetal and neonatal
physiology. In the USA, this includes the Society for Pediatric Research (founded
in 1929 as the Eastern Society for Pediatric Research), and of which several accounts
have been written, including publication of the journal Pediatric Research (Bellanti
1980; Weil 1996). In 1959, the “No Name Society” was organized by Charles
Henning Hendricks (1917–2010) then at the Western Reserve University (now Case
Western Reserve University) in Cleveland, OH. The Society is distinguished by
having no members (attendance at meetings is by invitation only from that year’s
organizer, and all attendees must present provocative unpublished data for discus-
sion), no constitution, and no bylaws (a framed blank piece of paper). The key ele-
ment is unlimited discussion with stimulating new ideas. In its formative years,
clinician-scientists comprised the majority of the two dozen or so invitees, while
presently most are basic scientists in various disciplines of the reproductive sci-
ences. In 1970, saw the beginning of the Perinatal Research Society (PRS), a group
of about 150 rather evenly divided, with one-third each physician-scientists in peri-
natology and neonatology, the remaining third being in the basic sciences. In the
UK, the Paediatric Research Society serves a similar function (Cosgrove, http://
www.prs.nhs.uk). At a global level, the World Association of Perinatal Medicine
held its First World Congress in 1991 in Tokyo (Sakamoto and Takeda 1992). This
gathering of several hundred obstetrician perinatologists and pediatric neonatolo-
gists from various countries meets every 2 years or so at major centers, the most
recent Eleventh World Congress was held in 2013 in Moscow, Russia.
470 21 Early Years of the Society for Gynecologic Investigation…

21.3 The Fetal and Neonatal Physiological Society

Because it is to Geoffrey Dawes that the Fetal and Neonatal Physiological Society
(FNPS) owes its existence, it is only appropriate to consider its origin. As an out-
growth of his studies, in 1974 Dawes organized the first “Conference on Foetal
Breathing” in Oxford, UK, which included a group of only about a dozen individu-
als interested in this physiologic function. Over the next 6 years, meetings were held
in Oxford, and on the Continent at Malmö, Sweden, Nijmegen, The Netherlands,
Paris, France, and again in Oxford (Tables 21.1 and 21.2). As the number of obste-
tricians and pediatricians with an investigative bent increased, they joined develop-
mental physiologists to the group’s ranks, as they studied factors that influenced
fetal breathing movements such as the incidence, periodicity, and role of maternal
smoking and hypoxia, low blood sugar, and others. Although it became clear that
the rate of fetal breathing decreased significantly in response to these and other
stressors, the mechanism(s) of the regulation of these movements, under either nor-
mal or abnormal conditions, eluded explanation. By recording fetal brain electroen-
cephalic activity and eye movements, it became clear that during breathing
movements the fetus alternated between states of low voltage, high frequency EcOG
during which the rapid eye movements and breathing movements were predomi-
nant, and high voltage, low frequency state during which breathing and eye move-
ments were suppressed. Still later, it was demonstrated that limb (arm and leg)
movements accompanied these other activities. Thus, Dawes and the Oxford group
developed the idea of “sleep states” or “behavioral states” for the developing fetus.
In addition to the associations noted above, these behavioral “states” changed as the
fetus became more mature from 16 to 40 weeks gestation. Their geographic base
represented by attendees also expanded. In 1981, the group changed its name to
“International Conference on Foetal Breathing” meeting over several years in
Maastricht, The Netherlands, London, Ontario, Canada, and Malmö, Sweden
(Tables 21.1 and 21.2).

Table 21.1 Conference on Year Venue

foetal breathing
1974 Oxford, UK
1975 Oxford, UK
1976 Malmö, Sweden
1977 Oxford, UK
1978 Nijmegen, The Netherlands
1979 Paris, France
1980 Oxford, UK

Table 21.2 International Year Venue

conference on foetal 1981 Maastricht, The Netherlands
breathing 1982 London, Ontario, Canada
1983 Malmö, Sweden
21.3 The Fetal and Neonatal Physiological Society 471

In regards to the 1982 Meeting at the University of Western Ontario in London,

Ontario, Mark A. Hanson, (Fig. 20.1k, m) has recalled regarding Dawes,
… as someone who worked closely with him (although I was never directly employed at the
Nuffield Institute in Oxford) my memory is of an incredibly kind and supportive person
who did much to encourage young investigators such as myself to pursue contemporary
questions in fetal physiology. When I first showed Geoffrey some of our fetal chemorecep-
tor data, he urged me to present it at the FNPS in London, Ontario. I explained that I would
love to go but unfortunately my research grant was relatively small and did not include a
travel allowance. He immediately got out his cheque book and wrote me a personal cheque
to cover the airfare. Thus began my real association with FNPS.
(Letter from MAH to LDL, 12 March 2009)

At the 1984 meeting in Oxford, the topics of interest expanded beyond fetal
breathing activity to include endocrine, cardiovascular, neurobiological, and other
aspects of fetal and neonatal growth and development. In view of its enlarged scope,
the group again changed its name to the “Society for the Study of Foetal Physiology.”
Over the following 4 years, meetings were held at Haifa, Israel, Banff, Alberta,
Canada, Groningen, The Netherlands, and Cairns, Australia. At the 1989 meeting in
Reading, UK, a new feature was introduced, that of inviting an outstanding leader
in the reproductive sciences to present a plenary lecture. It should be noted, how-
ever, that this was not accepted without some controversy. Many members believed
that the meetings should consist wholly of short, 15 min free communications of
cutting-edge research by attendees, including postdoctoral fellows and graduate stu-
dents, rather than a “canned” lecture by some supposed notable. Despite such dif-
ference of opinion, the first of these special lectures was by Elizabeth Anne Linton
of the University of Reading, on corticographic releasing factor in pregnancy. Over
the next few years, this special lectureship was continued (see Table 21.3).
Among those who did not work with Dawes at the Nuffield Institute but fell
under his spell was Dino Antonio Giussani (Fig. 20.1 l, m), of Cambridge University.
Giussani has recalled some details of the 1991 meeting of the FNPS.
… one of my fondest and most cherished memories … was at my first FNPS meeting in De
Eemhof The Netherlands in 1991, soon after completing my first year of PhD training.
Being South American, I remain convinced to this day that one of the main reasons for
Mark Hanson employing me was because of my footballing skills, as in De Eemhof the
traditional sporting event was to be football. Having been introduced to the ‘ins and outs’
of the Society by endless anecdotes told by the then Post-Docs of the lab … you can imag-
ine that I looked forward to participating at these social events so impatiently. I always
wondered what would be the effect of putting several driven scientists at the same time in
the same sporting field and, needless to say, often pondered whether that would be such a
good idea. Well, at 5 o’clock in the afternoon of May 8th 1991 at Center Parcs De Eemhof,
one of the main organisers of that meeting, Dr Jan Nijhuis, placed a whistle around Geoffrey
Dawes’ neck and asked him to Referee THE football match. I cringed having realised that
I was placed on the same side as Mark Hanson and Carlos Blanco, both of whom wore
rather high-cut running shorts and certainly did not look the part! I also remember that the
‘opposition’ was particularly ominous-looking, with players such as Bill Gilbert, Edu
Mulder, Hugo Lagercrantz, Bob Brace and Gerry Visser. The game started and rather than
a sport, the activities of both teams better resembled a very poor effort of trying to illustrate
the application of the chaos theory to fetal heart rate variability. Almost 20 minutes into the
game, John Spencer on our side crossed the ball with unexpected accuracy into the
472 21 Early Years of the Society for Gynecologic Investigation…

Table 21.3 Society for the study of foetal physiology

Year Venue Speaker Title
1984 Oxford, UK – –
1985 Haifa, Israel – –
1986 Banff, Alberta, Canada – –
1987 Groningen, The – –
Netherlands
1988 Cairns, Australia – –
1989 Reading, UK Elizabeth A. Linton, Corticotrophic Releasing
University of Factor in pregnancy
Reading
1990 Asilomar, Pacific Grove, Betsey Rasmussen Reproductive chemical communi-
California, USA cation in elephants, other
mammals and fish
1991 De Eemhof, The Dick F. Swaab, Development of the human
Netherlands University of hypothalamus in relation to
Amsterdam birth
1992 Niagara on the Lake, Alan Bernstein, The doctor’s dilemma: molecular
Ontario, Canada University of biology and the future of
Toronto biomedical research
1993 Plymouth, UK Euan Brown, Stazione Squid, sex and science in the
Zoologica Anton southwest: Marine biology with
Dohrn, Napoli a medical slant in Plymouth
1994 Palm Cove, Australia – –
1995 Malmö, Sweden Geoffrey S. Dawes, Control of fetal behaviour
Oxford University

opposition’s penalty area. Mark Hanson dove hopelessly head-first into the vicinity of the
area pretending to make contact with the ball, only to be met by the boot of Hugo Lagercrantz
which he had raised in Bolshoi-style well above the height allowed. Geoffrey blowed the
whistle with deafening volume, Mark ended up with a double rib fracture and Hugo was
concussed for a while. Five minutes later, the game carried on. It was at that precise moment
that I knew I had made the right choice of subject and that fetal physiology would remain
part of my entire life.
(Letter from DAG to LDL, 20 July 2009)

At the August 1994 21st Annual Meeting in Cairns, Australia, the first of the
meetings that I attended, although unable to be present, Dawes wrote a letter to the
attendees on origins of the Society. This is given as follows,
Between 1970 and 1975 one of the interests of the Nuffield Institute for Medical Research,
Oxford, was the exploitation of the rediscovery of normal fetal breathing movements in
utero, in sheep and man. Acute hypoxia caused an arrest of fetal breathing, in contrast to the
hyperventilation seen in normal adults. Was this helpful in identifying sick fetuses? Could
the technology be improved to record breathing movements more directly, or more accu-
rately, using ultrasound? On April 25, 1975 we held a one-day meeting, to which visitors
with skills in ultrasound technology or in clinical obstetrics contributed, as well as the labo-
ratory staff, about three dozen all told. The discussion proved useful, and it was decided to
hold another meeting on 3 October 1975, the day before a meeting of the Blair Bell (obstet-
ric research) Society was due to be held in Oxford to obtain the views of more people,
21.3 The Fetal and Neonatal Physiological Society 473

especially from overseas. The discussion again ranged widely over the physiological,
pathophysiological, clinical and technical problems of recording fetal breathing move-
ments. The introduction of real-time ultrasound was about to revolutionise the clinical
scene and reveal the fetus in utero for all see. But alas, no record was kept of the discussion,
and I do not even have a list of the participants of these two meetings.
As a consequence, Gerhard Gennser and Karel Marsal organized a further meeting “The
Third Conference on Fetal Breathing” in Malmö, Sweden on 8 June 1976. In their report of
the proceedings they quote Lord Kelvin [First Baron Kelvin, Title of William Thomson
(1824–1907)] “I often say that when you can measure what you are speaking about, and
express it in numbers, you know something about it; but when you cannot express it in
numbers, your knowledge is of a meagre and unsatisfactory kind; it may be the beginning
of knowledge but you have scarcely, in your thoughts advanced to the stage of science,
whatever the matter may be” [(Thompson, Letter to the Institution of Civil Engineers,
3 May 1883)]. Gennser and Marsal go on to say that “The significance of the present
Conference, the third to be held… lies, in our minds, in emergence of techniques yielding
valid results and in the clinical application of the measurements. This is no minor achieve-
ment since less than 5 years has passed since Boddy and Robinson published the first ultra-
sound recording of human fetal breathing”.
The meetings settled at once into an annual pattern, within Europe. The first outside
Europe was in London, Ontario, Canada (1982) with which there were close connections to
Oxford through many exchanges of visiting scientists. [I now have a red-headed grandson
studying there, in the University of Western Ontario and hope thereby to keep contacts with
old friends]. There was, from the beginning, pressure to widen the scope of the meetings,
especially from Geoff Thorburn. By the eighth meeting, at Maastricht (Holland) in 1981, it
had become an international conference “on fetal breathing and other measurements”. By
1984 it was a meeting of the Society for the Study of Fetal Physiology. There were 34 oral
communications and 26 posters at this meeting in Oxford ten years ago, covering a very
wide range of fetal studies in animals and man. Nevertheless the fetal applications of molec-
ular biology were slow to appear. Will they have a revolutionary effect? You must tell me.
Indeed I am desperately sorry to miss this meeting, the first I have not attended, the 21st
in the 20th year. Hurrah for the Fetal and Neonatal Physiological Society I shall try to come
next year.
Now to more serious things. Tom Kees Anton Bonifacius Eskes (1933–2011) and
Lawrence Longo have recently selected a group of classic contributions of “innovative
papers”1 But they have omitted all reference to a transient and fascinating art from, which
illumined the hearts and minds of all good men, that is, you and me. Some of our early
meetings were enlivened by elegant draughtsmanship, on the outer cover of the volume of
Proceedings. That in Malmö (1976) had the human fetus, in 5 stages of development, dis-
cussing its situation in Latin. By 1979, in Paris, it had broken free of the mother and was
happily snorkeling in the amniotic fluid. Was this The Concept of Fetal Autonomy? A year
later, in Oxford a thoughtful ewe was sitting on her rump, listening through a stethoscope
to the fetal heart, taught no doubt by Jeff Robinson, who can do anything with sheep. There
are other ideas to conjure with, now we know that the mature fetus can hear all that a mother
says. I plead with you not to let this form disappear. What should we be thinking of next
year? The younger and the more irreverent the draftsman the better. Don’t we also need a
LOGO? And a shortened title, such as International Fetal and Neonatal Physiological
Society or INFANTS. That word is happily derived from the Latin, and means “inability to
speak”.
Au Revoir, Geoffrey Dawes (Personal Communication)

1
Here Dawes refers to Eskes and Longo, 1993.
474 21 Early Years of the Society for Gynecologic Investigation…

At the 1995 Malmö meeting, a year before his death, Geoffrey Dawes reviewed
his and others’ work on the control of fetal behavior. It was at the 1996 meeting in
Arica, Chile, the first in South America, that the designation of the Society was
changed again. This time to the more inclusive “Fetal and Neonatal Physiological
Society.” A Mission Statement was adopted that included the following.
1. The Fetal and Neonatal Physiological Society encourages research and dissemi-
nation of knowledge in the field of fetal and neonatal physiology, broadly
defined.
2. The Organizational Coordinator will be selected by the Organizational
Committee, and shall serve for 3 years.
3. The Organizational Committee shall consist of representatives from Africa,
Asia, Australasia, Canada, Continental Europe, South America, UK, and USA,
and shall be selected by the Committee.
4. The Annual Meeting will be held in Europe, North America and the Southern
Hemisphere, in approximately equal proportions, in June–September, as deter-
mined by the Organizational Committee.
5. The membership list of the Society shall consist of those participants registered
for any of the past three meetings, and this shall serve as the mailing list for the
subsequent meeting.
6. Any residual funds from prior meetings shall be passed on to the Coordinator of
the next meeting. Audit will not be required if the residual funds are <$US
10,000.
7. The Organizing Committee shall have the right to solicit funds in the name of the
Society from organizations, for the purpose of providing financial support for
students and fellows-in-training to attend meetings.
Following the Arica meeting, annual gatherings were held in Italy, the USA, and
The Netherlands (See Table 21.4). It was at the 1998 meeting, 2 years following
Dawes’ death, that Brian J. Koos of University of California, Los Angeles, who had
organized the meeting, elected to use funds collected in excess of expenses to estab-
lish a keynote address, designated the “Geoffrey S. Dawes Lecture.” The first of
these presentations was by Jack L. Feldman of University of California, Los
Angeles. At the 2002 meeting, held in Prague, Czech Republic, the mission state-
ment was modified somewhat, to state, “The FNPS stimulates discussion and
exchange of ideas between physiologists, obstetricians and neonatologists. The
FNPS considers an informal gathering and presentation of new and preliminary
data, especially by investigators in training, essential to achieve goals.”
21.3 The Fetal and Neonatal Physiological Society 475

Table 21.4 The fetal and neonatal physiological society

Year Venue Geoffrey S. Dawes lecturer Title
1996 Arica, Chile Peter W. Hochachka, Deep, Prolonged Diving in Large
University of British Seals: Metabolic Marvels and
Columbia Metabolic Mysteries
Alan H. Jobe, Harbor-UCLA The Future of Surfactant and
Medical Ctr Surfactant Research
1997 Santa Margherita Alberto Piazza, University of A History and Geography of
Ligure, Italy Turin Human Genes
1998 Lake Arrowhead, Jack L. Feldman, University Pre-Botzinger Complex: the
California, USA of California, Los (proposed) Site of Respiratory
Angeles Rhythmogenesis
1999 Vlieland, The Christine L. Mummery, Embryonic Stem Cells and
Netherlands Netherlands Institute for Cloning in Humans: Present
Developmental Biology and Future
2000 Southampton, UK David J.P. Barker, University The Biological Origins of
of Southampton Coronary Heart Disease
2001 Auckland, New Ruud Kleinpaste, New Bugs in the System
Zealand Zealand Entomologist
2002 Prague, Czech Anthony M. Carter, Phylogenic Aspects of Placental
Republic University of Odense Development
2003 Banff, Alberta, Peter D. Gluckman, Fetal and Perinatal Brain Injury:
Canada University of Auckland the Development of
Therapeutic Approaches
2004 Tuscany, Italy L. Angelo Vescovi, Functional Properties of Neural
University Stem Cells and their
of Milano - Bicocca Therapeutic Potential
2005 Glenelg, Australia Jeffrey S. Robinson, The “Fatal Fetus”
University of Adelaide
2006 Cambridge, UK Stephen O’Rahily, University Human Obesity and Insulin
of Cambridge Resistance: Lessons from the
Extremes
2007 Sendai, Japan Hitoshi Oshitani, WHO Avian Influenza and Pandemic
Western Pacific Regional Threat
Office
2008 Maastricht, The S.E. Buitendijk, TNO Measurement of Perinatal
Netherlands Netherlands Mortality in the European
Context
2009 Lake Arrowhead, Lawrence D. Longo, Loma Geoffrey S. Dawes and the Rise
California, USA Linda University of Fetal and Neonatal
Physiology
2010 Winchester, UK Colin Sibley, University of Placental Physiology in the
Manchester twenty-first Century: Using
the Knowledge
2011 Palm Cove, Australia Richard Harding and David From Oxford to Melbourne, Two
Walker, Monash Extraordinary Contributions
University
2012 Utrecht, The Gerard H. A. Visser, UMC An Exciting Time for
Netherlands Utrecht Obstetricians
476 21 Early Years of the Society for Gynecologic Investigation…

References

Assali NS (1979) A doctor’s life. Harcourt, Brace, Jovanovich, New York, NY

Assali NS (1994) A journal at last! J Soc Gynecol Invest 1:2
Bellanti JA (1980) Pediatric research: challenges to be met and promises to keep. Pediatr Res
14:1282–1289
Herrmann WL (1970) Editorial. Who needs a new journal? Gynecol Invest 1:1–3
Lobo RA (1994) Editorial. J Soc Gynecol Invest 1:1
Longo LD (1983) A short history of the Society for Gynecologic Investigation, 1953–1983. The
Author, Los Angeles, CA
Longo LD (1992) Preparing for the twenty-first century in the reproductive sciences: the history
and present status of research training in obstetrics and gynecology. In: Townsend J (ed)
Strengthening research in academic OB/GYN departments. Committee on Research
Capabilities of Academic Departments of Obstetrics and Gynecology, Division of Health
Sciences Policy, Institute of Medicine, National Academy of Sciences, National Academy
Press, Washington, DC, pp 229–267
Longo LD (2000) The Society for Gynecologic Investigation at the millennium. J Soc Gynecol
Invest 7:S55–S99
Naftolin F, Horvath T (1994) Providing a ‘Noah’s Ark’ for research in the reproductive sciences by
fostering young investigators: a role for our journal. J Soc Gynecol Invest 1:246
Sakamoto S, Takeda Y (1992) Advances in perinatal medicine. Proceedings of the First
International Congress of Perinatal Medicine, Tokyo, 5–8 November, 1991. Excerpta Medica,
Amsterdam
Weil WB (1996) The Society for Pediatric Research: from infancy to adulthood in sixty-five years.
Pediatrics 97:129–136
Chapter 22
Epilogue

If we are to vindicate the claim to be seeking the nature of

things, then it must be extensive. The broad picture must be
sought, outworn detail discarded, and all help possible derived
from simplifications and generalizations … This is no doubt
more easily said than done, but whoever believed that our task
is an easy one? Nor is our responsibility lessened by the need
… of guarding against the superficial and the inaccurate, of
deriving full benefit from the intensive approach and from
special disciplines, and of combining the survey of the
small-scale map with the detailed scrutiny of the large-scale
insets.
(Sir Cyril Hinshelwood 1954, p. 307)

22.1 The Adventure of Science

As noted in the introduction, the Oxford chemist and Nobel Laureate Sir Cyril
Hinshelwood defined science as “… an imaginative adventure of the mind seeking
truth in a world of mystery” (Hinshelwood 1954, p. 301). In the lines quoted above
he cautioned that the quest is not without its challenges. Science constitutes an end-
less quest of nature for knowledge and wisdom. Unique among fields of mental
enterprise, it requires curiosity, creativity, and dedicated work, and is characterized
by communalism, universalism, disinterestedness, originality, and skepticism.
Science possesses an informal quality-assurance system of peer-review, publica-
tion, and independent replication. As noted earlier, this essay might be viewed as a
case study in the manner in which a special field of biomedical science has emerged
and continues to evolve, and the way in which individuals, their ideas, and social
forces critically interact in that development. As with much of contemporary bio-
medical science, fetal and neonatal physiology is based in general on the “Galilean-
Harveian” hypothetico-deductive method, with the careful analysis of observed
phenomena, generation of a testable hypothesis, designing and recording of experi-
ments to test these hypotheses, and the further wholesale collection of observations
and data to explore a more refined hypothesis. These are generated in sufficient
detail to extend beyond mere empirical observation, and allow the innovation of
quantitative reasoning to establish a proposed general principle and to enable
reproducibility.

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 477
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_22, © American Physiological Society 2013
478 22 Epilogue

Because the approach to scientific investigation is such a critical aspect of fetal–

neonatal physiology, it may be of value to consider its several approaches. As noted
earlier, in his efforts to understand the living organism, William Harvey was the first
investigator in biology to employ the methods of science as presently conducted,
that is: observation, hypothesis, deduction, experiment, reformulation of hypothe-
sis, and further observation. This path follows neither scholastic Aristotelianism nor
the Baconian (named for the visionary English philosopher and essayist Sir Francis
Bacon), laborious accumulation of data, its manipulation by the complex tables of
the Novum organum, and its inductive method (Bacon 1620a, 1620b, 1623; see
Whewell 1837). During the late-nineteenth and early- to mid-twentieth centuries, as
with related fields of biomedical science, physiology moved from being descriptive
and phenomenological to hypothesis-driven experimentation. For instance, in his
Introduction à l’étude de la médicine expérimentale [Introduction to the study of
experimental medicine], Claude Bernard presented the basic principles of physio-
logic investigation as applied to the life sciences (Bernard 1865). Included in this
approach is the increasing dominance of reductionism, the concept that complex
biological systems can be understood only by dismantling them into their constitu-
ent components, and to explore each in isolation. Implicit, is the idea that experi-
mental observations should be made to support or attack a given hypothesis of a
phenomenon or mechanism of action. In this paradigm, straightforward observa-
tion/phenomenology for its own sake is of limited value. Further, as noted, the rigor
of scientific investigation has included the concepts of blinded, randomized design,
repeatability of experiments to establish their validity, peer-review evaluation of
manuscripts for publication, and independent confirmation from other laboratories.
Based on empirical a priori experience, over the past half century these standards
and approaches have served the biomedical community well, witness the revolu-
tions in cellular and molecular biology, genetics, neuroscience, endocrinology,
immunology, and the multitude of advances in related disciplines. As a conse-
quence, the complexity of biology has grown by orders of magnitude. At times
delving into it, seems as though one were entering a Mandelbrot [named for Benoît
Mandelbrot (1924–2010)] set of complex dynamics and abstract mathematics, e.g.,
that space determined by a relatively simple equation, but as one approaches its frac-
tal boundary, ever more intricate patterns of complexity are revealed (Mandelbrot
1977, 1982).
Philosophers of science have supported, challenged, attacked, or otherwise
attempted to modify this hypothetico-deductive approach over the years, stressing
rather the metaphysical, epistemological, semantic, or other aspects of science. For
instance, in the early twentieth century, the polymath Michael Polanyi (1891–1976)
advanced the idea of the social construction of science. That is, science proceeds by
something other than strict rationality or algorithmic procedure, arising rather from
a mélange of social processes that no purported-scientific method could capture. In
his Science, Faith and Society (Polanyi 1946), Personal Knowledge (Polanyi 1958),
and The Tacit Dimension (Polanyi 1966), Polanyi spelled out his opposition to a
positivist account of science, claiming it to be a relativistic discipline, and that abso-
lute objectivity is a false ideal. As noted in the Preface, following Polanyi’s role in
22.1 The Adventure of Science 479

initiation of the “science wars,” another to challenge the triumphal tales of upward
and onward scientific processes was the philosopher of science Thomas Kuhn. In
his The Structure of Scientific Revolutions (Kuhn 1962), Kuhn furthered the idea of
the sociological construction of science, denying the concept that science progresses
in a linear, continuous manner. Rather, he postulated that science progresses by
periodic “paradigm changes” or shifts that revise dogma and open new vistas of
understanding. Kuhn also argued that rather than being established by objective
criteria, the notion of “scientific truth” often is defined by consensus of the scientific
community. A fiftieth anniversary fourth edition of Kuhn’s work, includes a percep-
tive essay that places it in the context of contemporary scientific, historical, and
philosophical thought (Kuhn 2012).
Healthy skepticism is of course an essential element of the scientific process. The
philosopher of science Sir Karl Raimund Popper (1902–1994), of the London
School of Economics, Fellow of the Royal Society, and 1992 awardee of the Kyoto
Prize in Arts and Philosophy, contended that the central problem in science is to
distinguish science per se (e.g., that based on observation) from non-science (e.g.,
logic, metaphysics, and so forth); that is, a theory of demarcation or “critical
rationalism,” as he called it. Popper argued against the Baconian insistence on the
primacy of observation per se, noting that all observation is selective and theory-
incumbent, and that rather than the espousal of any unique methodology, science
consists of problem-solving. In Popperian epistemology, a central requirement of
science is to falsify hypotheses (Popper 1959, 1999; Thornton 2011). Popper cau-
tioned, that if we respect truth we must search for it by persistently searching for our
errors. So arose the Popperian thesis of falsification, e.g., that a given hypothesis
cannot be proved, only shown to be false. Among contemporary philosophers of
science, a rather extreme extension of this view holds that a hypothesis can neither
be proven nor disproven (Atkinson 1985; Kinraide and Denison 2003; Lipton 2005;
Weimer 1979).
In his Jayne Lectures to the American Philosophical Society, the 1960 Nobel
Laureate in Physiology or Medicine, Sir Peter Brian Medawar (1915–1987) agreed,
in part, with this view, observing,
Ask a scientist what he conceives the scientific method to be, and he will adopt an expres-
sion that is at once solemn and shifty-eyed: solemn, because he feels he ought to declare an
opinion; shifty-eyed, because he is wondering how to conceal the fact that he has no opinion
to declare. If taunted he would probably mumble something about “Induction” and
“Establishing the Laws of Nature”, but if anyone working in a laboratory professed to be
trying to establish Laws of Nature by induction we should begin to think he was overdue for
leave.
(Medawar 1969, p. 11)

As articulated by Bacon, Medawar also emphasized that although much original

research begins with experimentation, it must progress beyond that. His exegesis cri-
tiqued both the Baconian-inductive approach to science, and the Harveian “hypothetico-
deductive” scheme of thought and Popperian “falsifiability.” He noted further,
Scientific reasoning is an exploratory dialogue that can always be resolved into two voices
or two episodes of thought, imaginative and critical, which alternate and interact. In the
480 22 Epilogue

imaginative episode, we form an opinion, take a view, make an informed guess, which
might explain the phenomenon under investigation. The generative act is the organization
of a hypothesis … (which) we can expose to criticism, usually by experimentation.
(Medawar 1969, p. 46)

Medawar stressed the requirement by a combination of intuition and good sense,

to move beyond compiling an inventory of factual information, to arrive at “… a
logically articulated structure of justifiable beliefs about nature” (Medawar 1969, p. 59).
Further, some contemporary philosophers of science would argue that science pro-
ceeds optimally by a combination of a more rigorous hypothesis-based deduction to
derive the particulars and refine the hypothesis, combined with Baconian-induction
from particulars to formulate general principles and theories (For instance, see
Nabel 2009; Theocharis and Psimopoulos 1987).
This quasi-metaphysical background to the philosophy of science having been
given, we must recognize that the decades encompassed in the present essay were in
many regards another era. Late early- to mid-twentieth century saw the flowering of
systems physiology, by which scientists gained considerable insights into various
organ systems with their individual tissue functions, regulation, interrelationships,
and feed-back loops. Initial endeavors along this line pursued problems in the physi-
ology, biochemistry, and pharmacology of the adult organism. Slowly, dawned the
realization that the developing fetus and newborn do not constitute small adults, and
the field generated its own set of problems to explore with hypotheses to test.
Currently, the opportunities in science are unbounded. For physiology, the past half
century has been a golden age, with creation of a new geography of science.
As noted, it was Claude Bernard that in the latter-nineteenth century presented a
rigorous outline of the scientific method in experimental physiology (Bernard
1865). It was at mid-twentieth century that the study design for clinical investiga-
tion changed from retrospective to prospective, from observational to experimental,
from uncontrolled to randomized controlled experiments. Laboratory investigation
of cellular and molecular biology emerged from this chrysalis. As all-encompassing
disciplines, which in bringing fresh insights invigorated every field, by the end of
the century dominated biomedical thinking. With the convergence of diverse disci-
plines fueling the expansion of research, and with the underpinning of ingenious
and complex contemporary tools, emerged genomics, transcriptomics, epigenom-
ics, proteinomics, metabolomics, and other “omics,” coupled with bioinformatics
and information technology. These disciplines have accelerated the pace of biologi-
cal discovery and expanded the boundaries of the worlds to be explored. Even the
past decade has witnessed fundamental shifts, with the experimental landscape
changing exponentially as the rate of discovery accelerates. Remarkable technologi-
cal advances in molecular genetics, advanced optical laser scanning confocal,
atomic force, and electron microscopy, novel approaches to fluorescently labeled
proteins with ever more sensitive imaging capabilities of subcellular localization,
protein–protein interactions, nanotechnology, live cell dynamics, high throughput
genomic and proteomic approaches, and the ability to manipulate proteins and other
modalities are leading to the elucidation of the most basic mechanisms of cellular
functional biology. Discovery of nuances of membrane receptors, trans-membrane
22.1 The Adventure of Science 481

trafficking, genome organization and gene regulation, allow the imaging of specific
subcellular signaling molecules their pathways and networks, and their location/
movement within subcellular organelles, and details of cytoskeletal dynamics.
These also permit a better understanding of transcription and translation regulatory
mechanisms including that of gene expression and thus biological function by small
noncoding RNAs. Revealing the role of these small microRNAs, with the histones
and other constituents now allow a new level of description of physiologic regula-
tion beyond the classic dogma of DNA → mRNA → protein. Coupled with other
major conceptual breakthroughs and “shifting paradigms,” these advances promise
to have an enormous impact on both understanding in the basic sciences and on the
role of physiology in integrating the findings of reductionism into clinical/transla-
tional research in the study of disease. Within the past decade in the reproductive
sciences, including embryonic development and fetal and neonatal physiology,
these methodologies have come to the fore, contributing greatly to our
understanding.
In a sense, this period is reminiscent of the late-fifteenth and sixteenth centuries,
with exploration and discovery of new lands, previously unknown peoples, and a
profound paradigm shift in concepts and understanding of the world. Indeed, pres-
ently we are in the midst of a second Renaissance, a vibrant Zeitgeist [spirit of the
age] and culture of discovery. It is a most exciting time in biomedical science, and
we can be allowed to possess great hopes and expectations. Although we face chal-
lenges, for physiologists there are enormous opportunities to take advantage of these
new methodologies and approaches, and thus to gain increased understanding of
fundamental biologic mechanisms of high relevance. As recognized, the ever rising
tide of microarray genomics and other “-omics,” demonstrates a shift from a
deductive-hypothesis based approach to questions of natural phenomena, to data-
driven “discovery.” This is not to attempt to transcend reductionism, as with such
discovery one can pose important hypotheses to test and unravel fundamental mech-
anisms. Physiologists then, as “integrative” and regulatory biologists, form the
bridge between cellular and molecular discovery, working to understand fundamen-
tal mechanisms of bodily function, the pathobiology of disease, and the challenges
of patient care. For fetal and neonatal physiologists, as with all other biomedical
scientists, the goal is to continue to pursue and uphold the core values of science:
objectivity, independence, self-critical thinking, and a relentless urge to explore the
most important problems within our ken, with unwavering commitment to fulfill
these ambitions.
As noted, Sir Isaac Newton and others before him, observed that if today we see
further, beyond the hills and rivulets of our predecessors, it is because “… we stand
on the shoulders of giants” (Merton 1965). Bertolt Brecht (1898–1956), the German
dramatist and poet, observed in his Leben des Galilei [Life of Galileo] “Science has
only one commandment: contribution” (Brecht 1938–1939). This constitutes part of
the life and vitality of science, it is the essence of progressivism in the life of the
mind. In an interview with the TV personality and commentator Charlie Rose, Jeff
Bezos cofounder of Amazon Books observed, “Our aim is to Invent the Future”
(Bezos, 26 February 2009). Despite almost exponential increases in our knowledge
and understanding, in many ways our situation is analogous to that of Sir Isaac
482 22 Epilogue

Newton, as we are but picking up bright pebbles by the seashore, while a vast
horizon stretches ahead.
We must beware of hubris, however. Among caveats to consider are our timidity
to think “outside the box,” to speculate and envision beyond our data and limited
information. In his essay “Speculation beyond speculation,” Julius Comroe
addressed this issue,
One problem here may be not what’s in the published article, but what’s not in it. In the
myriads of articles listed monthly in Index Medicus, what is usually not included is specula-
tion – an author’s ideas or suggestions reached by contemplation, reasoning, conjecture, or
surmise but not yet supported by sufficient hard data to merit separate publication. I specu-
late that we might speed the advance of medical science by inviting all authors to include
some speculation, labeled clearly as such in their scientific articles, to follow Introduction,
Methods, Results, and Discussion – and to precede and not to be confused with the author’s
well-fortified Conclusions.
(Comroe 1977, p. 343)

In addition, we face other challenges. In his 1967 lecture at the University of

Newcastle upon Tyne, the 1953 Nobelist in Physiology or Medicine, Sir Hans Adolf
Krebs (1900–1981) spoke on “The Making of a Scientist.” He emphasized the
importance of working under and being mentored by great teachers, the critical role
of centers of excellence with cross fertilization of ideas among colleagues, and the
importance of having adequate time for research with reflection (Krebs 1967).
These issues, vital to science, continue to face us today. As a corollary, despite rec-
ognition of multiple serious problems in the reproductive sciences, and the monu-
mental advances we have made much of which has resulted from support of
governmental agencies, the MRC, NIH, and others, the amount spent on research
for the diseases of women and their fetuses, infants, and children is miniscule com-
pared to that for waging war with its deadly toll. This, despite the importance of the
problems presented, and the incredible opportunities that lie before us.
In terms of the vital need for creativity in science, more than a century ago, the
French mathematician Jules Henri Poincaré (1854–1912) wrote,
To create consists precisely in not making useless combinations and in making those which
are useful and which are only a small minority. Invention is discernment, choice … Among
chosen combinations the most fertile will often be those formed of elements drawn from
domains which are far apart … The true work of the inventor consists in choosing among
these combinations so as to eliminate the useless ones…
(Poincaré 2000, pp. 87–91)

In terms of questions to explore, the mathematician David Hilbert (1862–1943),

of the University of Gottingen, once said that the vigor of a science can be measured
by the number and quality of the unsolved problems it addresses. To demonstrate
the viability of mathematics, at the 1900 International Congress in Paris he formu-
lated a dozen (later expanded to 23) “Problems of Mathematics” that he believed to
be of fundamental importance. Although several of these were solved within a short
time, some continued to engage mathematicians throughout the twentieth century
(Weyl 1944). A challenge in the new century, is to identify and explore the physio-
logic problems and enigmas of most fundamental and general significance to life.
22.2 Fundamental Research, Clinical Medicine… 483

For fetal and neonatal physiologists, as well as all scientists, an essential require-
ment is to be as rigorous as possible in designing and conducting experiments.
Several decades ago, the biophysicist John Rader Platt (1918–1992) considered the
basis on which some fields of science such as molecular biology and nuclear phys-
ics experience rapid progress, while other fields languish. As he outlined with a
Popperian view, we must formally, explicitly, and regularly have multiple working
hypotheses, design crucial experiments to exclude, e.g., falsify one or more of these,
and conduct our experiments so as to obtain clear results. This path of “strong infer-
ence,” with multiple working hypotheses, must then be reformulated into a branch-
ing logic tree to refine the possibilities and hypotheses (Chamberlin 1965; Hiebert
2007; Platt 1964). With its systematic use of the scientific method, this approach is
of inestimable value in terms of economy of time, money, and experimental
resources (Davis 2006; Kinraide and Denison 2003; Wenner 1989). Despite certain
limitations with the Popperian-Platt approach, in terms of being able to prove or
disprove a given hypothesis (Kinraide and Denison 2003), the correction of compet-
ing hypotheses and rationale has transformed science, and our understanding of the
world. Also a consideration in the concept of multiple working hypotheses is that of
Bayesian [named for the English cleric of Dissenters, Thomas Bayes (ca. 1702–
1761)] inference (Bayes 1763, 1958). That is, by repeated experiments and updating
of the probability estimate for a given hypothesis, one can approximate with greater
accuracy the value of a given function (Howson and Urbach 2005; Jensen 1996).
A cautionary note, however, is not to have one’s perspective distorted by the patina
of precision of some statistical methods, and be blinded by the “Haze of Bayes”
(Feinstein 1977). In this regard, as physiologists we do well to not ignore the onto-
logical parsimony of Occam’s Razor, named for the English Franciscan friar
William of Ockham (ca. 1288–1348), in theory always opt for an explanation in
terms of the fewest possible causes, factors, or variables. In his consideration of
“Emergent phenomena…,” the Canadian physiologist Peter T. Macklem (1931–
2011) stressed the vital role of physiology in obtaining a deep understanding of life
and its secrets (Macklem 2008). In its essence, the seeking of understanding the
mysteries of our world’s living things is what biomedical science is all about.

22.2 Fundamental Research, Clinical Medicine

and the Role of the Physician–Scientist

In addition to gaining an understanding of fundamental mechanisms per se, of criti-

cal importance so as to minimize morbidity and mortality is the need to apply these
insights and understanding to clinical problems in medicine. In his consideration of
the manner in which basic research has contributed to a number of advances in clini-
cal medicine, the 1962 Nobel Prize Laureate in Chemistry, Max Ferdinand Perutz
(1914–2002), of the MRC Laboratory of Molecular Biology, Cambridge reflected,
484 22 Epilogue

These concepts and techniques were developed by scientists who set out to interpret funda-
mental biological processes in physical and chemical terms. Generally the problems were
so complex that it took very many years to solve them. At the outset our ignorance was too
profound for us to foresee the relationship of our work to human disease, and it became
apparent only afterwards. Although we know more now than when we started, molecular
biology is still too young a science for it to be clear exactly where it will pay off, whence
we may do best if we spread our efforts over a wide field. Since research is the art of the
soluble, it is often more profitable to study a basic problem in microorganisms where it can
be solved, rather than in mammalian cells which are so much more complex. One of my
examples has shown how such an indirect approach has helped to unravel pathogenic events
in man. It would be a mistake if all molecular biologists switched to mammalian cells as has
recently become the fashion, or as they are being forced to do by policy decisions of sup-
porting agencies. There is a unity of life at the molecular level which implies that anything
found to be true in E. coli may also hold in man.
(Perutz 1976, p. 453)

The same year as the appearance of Perutz’ paper, Julius H. Comroe, Jr. and Robert
Dunning Dripps (1911–1973), the latter of the University of Pennsylvania, published
the results of an exhaustive study in which they examined about 4,000 scientific
papers to identify those that contained critical information necessary for the treatment
of the “top 10” cardiovascular or pulmonary disorders. These included hypertension,
coronary insufficiency, cardiac resuscitation, congestive heart failure, cardiac and
vascular surgery. In consultation with over one hundred academic physicians, basic
scientists, and other consultants, Comroe and Dripps identified 20–30 essential bod-
ies of knowledge required for each clinical advance. As an example, for open heart
surgery these included: electrocardiography, cardiac catheterization, angiocardiogra-
phy, anesthesia, specific drugs, and so forth. Of the 529 key scientific articles judged
essential for these clinical advances, 41 % were in basic science. That is, of reports
critical to the advancement of the care of patients, at the time of their publication four
of ten contributions were directed to fundamental methodologies or understanding of
mechanisms not believed to be of clinical relevance. Comroe and Dripps concluded
that in addition to the need for investigation to be conducted on the nature of research
per se, much greater support was needed for biomedical research and its development
(Comroe and Dripps 1976). In a prepatory report “Ben Franklin and Open Heart
Surgery,” these authors had outlined their plan for this study, in which they stressed
the importance of basic, non-targeted or mission oriented research in laying the foun-
dation for translational-clinical advances (Comroe and Dripps 1974).
In his 1979 presidential address to the Association of American Physicians, then
National Institutes of Health Director James Barnes Wyngaarden warned of the
clinical investigator becoming an “endangered species.” With considerable insight
he noted, “The physician–scientist has a very special role both in posing relevant
medical questions and in applying new knowledge to the investigation of disease …
The future of clinical science depends on the quality and the numbers of new leaders
in the field” (Wyngaarden 1979, p. 1259). In a later address to the Association of
American Medical Colleges, Wyngaarden expanded upon the view that “… the
application of scientific advances to maintain good health and to prevent and treat
diseases, ultimately is the responsibility of the physician. The trained clinical
22.3 Fetal and Neonatal Physiology and Its Relation to Physiology in General 485

investigator is the critical link between the laboratory and the health care provider.
In the face of the explosive growth of basic knowledge in the biomedical sciences
… the shortfall in training of clinical investigators assumes additional significance”
(Wyngaarden 1984, p. 159). In addition to Wyngaarden (Wyngaarden 1983), the
critical need for physician–scientists in maintaining the biomedical-research
enterprise has been noted by many others (for instance, see Cadman 1994; Neilson
et al 1995; Rosenberg 1999; Schechter 1998).
More recently, Nobel laureates Joseph Leonard Goldstein and Michael Stuart
Brown, of the University of Texas, Southwestern, in Dallas, have emphasized the
urgent need to reinvigorate clinical investigation, the “intellectual core of academic
medicine.” They note that the clinical scholar with analytic insight is the limiting
factor in this process of revitalization (Goldstein and Brown 1997). As we com-
mence a new century, those of us in academic medicine need to evaluate carefully
where we are going in terms of advancing research in the basic sciences, in the
reproductive sciences, and in fetal and neonatal physiology.
Also not to be overlooked, by educating a generation of physician–scientists,
advances in the field have contributed greatly to the development of academic
departments of obstetrics and gynecology, pediatrics, and other fields. As part of
their training, such “bridge-builders” have cultivated the “investigative mind,” and
in addition to their research contributions, have served as mentors and role models
for students, residents, and fellow faculty (see Longo et al 1999; Longo and Jaffe
2008). A contemporary problem of concern is that of the physician–scientist as
beyond being an “endangered species,” but rather as with the passenger-pigeon and
many other species, near extinction. As Wyngaarden noted, the “… trained clinical
investigator is the critical link between the laboratory and the health care provider”
(Wyngaarden 1984, p. 159).

22.3 Fetal and Neonatal Physiology and Its Relation

to Physiology in General

As noted in the introduction, physiology “the Queen of the Biomedical Sciences,”

has a glorious history. However, as with so many aspects of its development, the
field of fetal and neonatal physiology has been a relative latecomer to this
Renaissance in contemporary science. Only towards the fin d’siècle, has it taken full
advantage of the powerful tools of cellular and molecular biology, to gain a deeper
understanding of the functions in the several areas of interest. Concurrently, devel-
opment of this discipline has played a central role in the advancement of physiology
in general, and allied sciences. Both from the standpoint of the basic sciences and
from that of translational/clinical applications, these investigations have contributed
enormously to an understanding of life and the betterment of humankind. In terms
of fundamental science, advances have proceeded at essentially every level: system,
organ, tissue, cellular, subcellular, and molecular. In many instances, this advanced
486 22 Epilogue

understanding has contributed to topics such as the hormonal regulation of physio-

logic systems; pulmonary surfactant, cellular effects of abnormal oxygenation
(hypoxia or hyperoxia), asphyxia, and ischemia, and the function(s) of essentially
every organ/system in the body. Although some would argue that systems and organ
physiology is passé, we would be reminded that despite the enormous advances and
insights that cellular and molecular biology has garnered, a number of vital ques-
tions in terms of function only can be addressed by integrative, translational physi-
ology. Thus, rather than an “either-or” approach to science and its support, we must
continue to advance integrative physiology/biology in a vertical approach at every
hierarchical level possible.
From the standpoint of clinical care, these advances in understanding of the
fundamental basis of functional mechanisms have led to enormous advances. For
instance, at mid-twentieth century the survival rate of premature infants weighing
~1 kg was ~5 %. Today it is 95 % or higher. Many other indices of progress in less-
ened morbidity and mortality could be cited. Despite these achievements, however,
we are faced with challenges for the future. As early as in his 1968 Presidential
Address to the Society for Pediatric Research, Norman Kretchmer (1923–1995),
then at Stanford University, observed that research in perinatology must become a
full-fledged science of human development, and that this constitutes both its defini-
tion and its challenge for the future (Kretchmer 1968). A decade later, as Director
of the NICHD, Kretchmer reiterated this view, stressing the paradox of the new
methodologies presenting a “burst of technological advance,” accompanied by the
simultaneous limitations in funding for cutting-edge research with “escalation of
costs.” Being “… charged with the responsibility of protecting the health of tomor-
row’s children as well as the health of today’s children,” Kretchmer noted the two
functions of scientific research, both to discover new findings and to identify areas
of ignorance. He concluded, “… as clinicians we have learned that we cannot apply
our present knowledge to the care of the patient without simultaneously applying
our present ignorance” (Kretchmer 1977, pp. 992–993). In a 1970 Symposium
Horizons in Perinatal Research. Implications for Clinical Care, Kretchmer endorsed
the power of the idea of considering the mother and fetus as a unit, investigation
providing knowledge of details of which will lead to ever greater reduction of fetal,
infant, and maternal morbidity and mortality (Kretchmer and Hasselmeyer 1974).
Another who considered the role of scientific research in contributing to health
and combating disease was Lewis Thomas (1913–1993), former Dean of the Schools
of Medicine at both Yale and New York University. Thomas made the prescient
observation,
If our society wishes to be rid of the diseases, fatal and non-fatal, that plague us the most,
there is really little prospect of doing so by mounting a still larger health-care system at still
greater cost for delivering essentially today’s kind of technology on a larger scale. We will
not do so by carrying out broader programs of surveillance and screening. The truth is that
we do not yet know enough. But there is also another truth of great importance: we are
learning fast. The harvest of new information from the biological revolution of the past
quarter-century is just now coming in, and we can probably begin now to figure out the
mechanisms of major diseases which were blank mysteries a few years back as accurately
and profitably as was done for the infectious diseases earlier in this century. This can be said
22.4 Fetal–Neonatal Physiology and the Future 487

with considerable confidence, and without risk of overpromising or raising false hopes,
provided we do not set time schedules or offer dates of delivery. Sooner or later it will go
this way, since clearly it can go this way. It is simply a question at this stage of events of
how much we wish to invest, for the health-care system of the future, in science.
(Thomas 1977, p. 46)

We are blessed to live in a world in which biomedical science continues to make

enormous progress. Virtually every issue of Cell, Nature, Science, and Proceedings
of the National Academy of Sciences, announces new triumphs in the accelerating
gain of new knowledge. Nonetheless, despite these accomplishments our ignorance
remains vast. As has been pointed out by others, in science the full fruition of our
studies depends upon three factors, the passion to know and to seek understanding,
the initiative to study and discover, and the awareness and ability to apply these.
“Highly specialized conditions have to be fulfilled before the plant will bloom,
before the flower will fruit and before the fruit will ripen” (Hinshelwood 1960, p. 424).
As this essay gives evidence, advances in fetal and neonatal physiology, with break-
throughs in related fields of science, have helped to lessen the gap between funda-
mental and clinical science, basic and translational, the theoretical and the practical.
Nonetheless, a vast gulf, a “no-man’s land,” or terra incognita remains. Our task
therefore is clear; it is to Persevere! By our efforts may knowledge, one of the great-
est instruments of highest ends, “advance, … mastery over environment increase,
drudgery be abolished, sickness healed, the people fed and life made happier”
(Hinshelwood 1960, p. 429). As biomedical scientists, we seek a vision of nature,
which may be expressed and communicated in an approach to understanding. With
the ever expanding mass of data, and the potential for further achievements in diag-
nosis and therapy, who can predict the future advances to be achieved? We must not
ignore the admonition of T.S. Eliot, poet, playwright, and critic, “Where is the wis-
dom we have lost in knowledge? Where is the knowledge we have lost in informa-
tion” (Eliot 1963, p. 147).

22.4 Fetal–Neonatal Physiology and the Future

One author has divided scientists into two groups, those who make it possible, and
those who make it happen (Calder 1951). Geoffrey Dawes and many of the other
investigators considered in these pages were influential in both of these roles. Rather
than simply enthusiasts of reductionism, with an historical view of scientific knowl-
edge and as determined scientists, they offered a distinctly self-critical, analytic
view of scientific investigation, one that challenged orthodoxy. With sound mind
and robust enthusiasm, their passion for science and for life was unbounded. In addi-
tion to furthering basic science, many were particularly mindful of the clinical
implications and relevance of their studies. In general, this nuanced, irenic approach
avoided the polemics of much of the ill-willed and ill-conceived contention, in terms
of the commonly accepted paradigm or set of assumptions, held by some in science.
488 22 Epilogue

With a broad vision of the experimental terrain, they carefully chose the questions to
explore. With a lucid pen, the writing styles of many were clear and succinct. Among
this group, Dawes became a doyen of developmental physiology and its exposition.
With the many investigators who “came of age” at the Nuffield Institute, they left a
legacy to be honored. As noted by John Challis in his Foreword, the names of
Dawes’ students and collaborators form a stellar roster of those who proved to be
leaders in developmental physiology/pharmacology and perinatal/neonatal medi-
cine. As one who sought to understand the regulation and integration of physiologi-
cal processes in developmental physiology, with multiple feedback systems at
successive levels of organization, along with his predecessors, Dawes was a seminal
figure. Without question, he left an enormous legacy, both in terms of science per se,
as well as in dedicating his career to educate and inspire young basic scientists, and
physician–scientists to become the future leaders in investigation and education.
A fundamental tenet of science is its international scope. Its advances and
achievements cannot be considered only in terms of contributions by a particular
organization or given country. Although discoveries that open new lines of investi-
gation are made by individuals, almost without exception others have expanded
upon and developed these further. Quite obviously, such achievements depend upon
the ideas and creativity of gifted individual investigators. Their fruition however, is
a function of opportunities, intellectual environment, the availability of technologi-
cal resources, financial support, and other social-cultural forces. Under Dawes’
direction, the Nuffield Institute was in many respects an Arcadia, a model of com-
bined individual brilliance, collaboration, and competition among its members.
With expansion and transfer of “offspring” to other centers, the Institute contributed
to the advancement of research and scientific progress throughout the world. With
his fine mind, being bright and well read with an awesome memory, Dawes was
blessed with a passion for excellence. With an infectious enthusiasm and basic
goodness, he was a first-rate mentor and role model. Some have said that “physiol-
ogy is not so much a subject as a point of view” (Franklin 1953, p. 344). Dawes and
many of the others exemplified this thesis. Those with an astrological bent might
view these events as a conjunction of the stars; the time was right for the opening of
a new field of science, the individual was right in possessing many gifts, being
focused, and having a platform at one of the world’s great universities from which
to work and expand his influence.
In recalling the eulogy of F.J.W. Roughton for Sir Joseph Barcroft noted earlier, the
same words may be said of Geoffrey S. Dawes. In one of his brief essays on the his-
tory of fetal and neonatal physiology, presented at a special symposium to honor him
and his life contributions, Dawes observed, “To discuss the past too long is neither
profitable nor interesting. To discuss the present is not easy … To discuss the future is
another matter altogether. If one could see far ahead, the word discovery would be
inappropriate.” Then in an allusion to the writings of St. Paul, he continued, “We see
through a glass, darkly.1 We have consistently underestimated the complexities of life
before birth” (Dawes 1985, pp. 829–830). In 1946, Dawes commenced his scientific

1
I Corinthians 13:12, King James Version.
22.5 What Lessons are to Be Learned? 489

life with a question, how to understand cardiorespiratory reflexes and responses to

stress. Five decades later, his final contribution also was a question, how will our
work, research, and new knowledge benefit human welfare?

22.5 What Lessons are to Be Learned?

In closing, several individuals have inquired as to what lessons, if any, I have learned
in surveying the literature and discussions with fellow scientists in preparing this
essay. Among those who learned of my efforts on this endeavor, I must admit that
several projected a dubious air, “who needs history?” They argued that the universe
of science is changing to such a great extent, and so rapidly, that history can contrib-
ute little to our understanding. “The past is another world, and that world is gone,”
one stated. In line with this argument, that philosophy which some would call “pre-
sentism,” appears to be not uncommon among many scholars who question an his-
torical perspective as being misleading, irrelevant, or even unknowable.
If for nothing else, it is hoped that the present synthesis will be of value to young
workers in the field, to satisfy their curiosity, and with the core of references, to give
them an appreciation of from whence we have come and the opportunity to pursue
in more depth some of the issues presented. Of course, history is more than “firsts,”
dates, and the lives of those who have gone before. I would suggest that it is about
getting things right, an anchor to the past, tracing influences and perceptive interpre-
tations of society and culture to shape our thinking. An historical perspective helps
to restore focus, and enables us to place our lives in the context of those individual
scientists whose works have shaped our thinking. By presenting another dimension,
it helps us to understand the present, to appreciate our limits, and to know ourselves
in a more meaningful way. It offers the opportunity to reflect upon the complexity
of life, and appreciate that despite how much we know, there exist a vastness that we
do not understand. Of the many uses of history, one is to inspire the present.
Hopefully, we can use this appreciation of the past to guide our future.
In an interview following publication of her blockbuster Silent Spring (1962),
Rachel Carson (1907–1964) is said to have observed, that sometimes the writer
doesn’t choose the subject, rather the subject chooses the writer (Carson 1962).
Perhaps that is the case in the present instance. Myths fill our lives, and are transmit-
ted from generation to generation. An historical view can fill us with a sense of
humility. Humility in appreciating how much we owe to those that have gone before,
and humility in the recognition of how much we have yet to learn. No one could
claim that historical synthesis produces definitive answers for all time; it is a pro-
cess, an evolution of sorts. As Samuel Reynolds observed, history traces the “many
slender threads” of our heritage (Reynolds 1978). Hopefully the tapestry woven will
help to present a cogent story of discovery as well as inspiration to others, a vision
of challenges that lie ahead, and of possibilities for further refinement.
Thus, among the questions we may ask are: For what kind of world of biomedi-
cal science should we strive, and how can we create it? Given our individual abilities
and the multitudinous technologies available, what are the most critical questions
490 22 Epilogue

that we can ask? How can we work so that, beyond being mere “stamp collectors,”
our discoveries be of utmost value, not just in gaining a better understanding of
fundamental mechanisms, but as importantly in contributing to more meaningful
lives for pregnant mothers and their infants and children. Within this context and for
the extent to which one can learn lessons, I would like to consider several major
issues.
First, I have come to appreciate more than ever before our rich heritage. In truth,
and as exemplified in many examples given, research in the basic sciences has made
enormous contributions in the endless war against disease, and to the well-being of
mothers and children. As an illustration of “translational” research at its best, one
could hardly have a more lucid and noteworthy example than fetal–neonatal
physiology. The many cases cited are foundations upon which contemporary care of
the pregnant mother and her newborn infant rest. Can we do more? Of course, that
is the challenge and opportunity for the support of bright young investigators to
invent the future.
To be a part of academic medicine is one of the most noble and rewarding life
experiences that one can imagine, and the opportunity to work with bright students,
gifted postdoctoral fellows, and passionate colleagues is unsurpassed. For me, with
the exception of Huggett and Sir Joseph Barcroft, I have known essentially all of the
key contributors to this discipline: Edward Adolph, Virginia Apgar, “Dr. B” Donald
Barron, Roberto Caldeyro-Barcia, Sid Cassin, John Clements, Robert Comline,
Kenneth Cross, Nicholson Eastman, Louis Flexner, Stan James, Ted Quilligan,
Elizabeth Ramsey, Sam Reynolds, Millie Stahlman, Leonard Strang, Geof Thorburn,
Wilfred Widdas, William Windle, and of course Geoffrey Dawes and others. Indeed,
these are some of the giants of basic, translational, and clinical research upon whose
shoulders we stand.
If I may be allowed a brief anecdote, it was in late 1962 or early 1963 that, as an
embryonic faculty member at UCLA, I spent 3 days squiring Professor Nicholson
Eastman of the Johns Hopkins Hospital around the Los Angeles area. He had come
to the campus to serve as a Visiting Professor, and my departmental chairman,
Daniel Green Morton (1903–1980) requested that I meet his airplane on arrival, and
chauffer him to the several hospitals and venues at which he would be speaking. As
background, Dr. Eastman had spent a year at the Rockefeller-funded Peking Union
Medical College in China. He lit up when he learned that I had spent a year and a
half in China as a US Army medical aid man during the latter part of World War II
and thereafter (1945–1946), and also that I had returned recently from spending
3 years in Nigeria, West Africa trying to “save the world” (which I didn’t). Notable
for me during this 3 day immersion, was the manner in which Dr. Eastman quizzed
me. In particular, several times each day he would confront me with what I viewed
as the major challenges facing the pregnant mother and her newborn infant, “what
are you going to do to improve maternal and child health?” or “what were my plans
to advance the specialty?” Regrettably, I do not believe that I ever gave him an
answer that satisfied his roving mind. Those 3 days changed my life, however.
Second, the Greek philosopher Democritus (fl. 500 BCE) is credited with saying,
“I had rather discover one true explanation than be the King of Persia.” Nothing is
22.5 What Lessons are to Be Learned? 491

more exciting or breathtaking than making a new discovery. As has been said, “…
life is not about how many breaths you take, but what leaves you breathless.” I am
struck that, in many respects, knowledge and understanding grow most rapidly in
the border zones between the sciences. In conjunction, is the appreciation that with
the rapid, exponential advances in science and technology, one of our challenges as
investigators is that we must be reinventing ourselves continuously to remain cur-
rent. And this is, in part, what makes it so exciting. Daily, we are learning and
expanding our horizons. Certainly for Geoffrey Dawes this was the case. Among his
achievements was to have developed an ambitious agenda, to have “sowed many
seeds of erudition,” and with that to have made discoveries with a profound reso-
nance for their time. Within the Nuffield Institute, he built a valuable edifice notable
for its scientific rigor and clarity.
Research, research, research, that is the key to unlocking the mystery of disease
and entering a paradise of health. As investigators, we are limited not so much by
existing technology, but by our curiosity and imagination. Importantly, we must
remember to “tie ourselves to the mast,” Ulysses-like, to remain true to the ideals of
science. We must avoid excessive enthusiasm for technology and instrumentation as
ends in themselves, rather than as tools to advance understanding. At the same time,
another of the challenges, and sometimes the most difficult question a scientist must
address, is the uncertainty of which of innumerable problems to pursue, what is the
most important question or innovative idea of which we are capable of addressing.
Of course, conducting research has its own challenges and difficulties. As a post-
doctoral fellow when I expressed frustration with the way things were going, my
mentor Robert E. Forster II at the University of Pennsylvania would respond, “If
research was so easy, everybody would be doing it.” It is never a “breeze” to con-
ceive of the great ideas or hypotheses to test. Performing the experiments is not
without unanticipated difficulties. Interpreting the results is not always straightfor-
ward. And writing up the results and getting them published in a first-rate journal is
not without its challenges. As is too well known, in many respects the process is
painfully slow and fraught with hurdles.
Somewhere, I have heard that there are “Ten Commandments” of what it takes to
be a successful scientist. These include: being reasonably bright, being curious and
having a passion for discovery with commitment to the work ethic, perseverance,
having lots of drive (not being complacent), choosing one’s mentor with care, pur-
suing a problem that is important, being creative, reading widely and being open
minded, remaining focused, not overreaching (choosing a project that is doable),
and being lucky! (the more the better).
Third, one cannot be but awed and humbled by the manner in which the field of
fetal–neonatal physiology has progressed. As noted, tracing its development is to fol-
low as a case study the evolution of biomedical science from organs and systems, to
the most subtle detailed and reductionist alchemy of subcellular mechanisms of cel-
lular and molecular biology. Some have likened this to a Rorschach ink blot test
(named for Hermann Rorschach (1884–1922); Rorschach 1921) which while it pos-
sesses a definable shape, is recognized by different individuals in terms of unique
patterns and unifying themes. It is a challenge of immense complexity, and is truly
492 22 Epilogue

multidisciplinary, with the common link of achieving an understanding of develop-

mental processes, that binds investigators together. As noted in the introduction, dur-
ing the past several decades the genomic revolution has somewhat overshadowed
classical physiology. Despite a tsunami of data, however, it remains for physiology
(systems biology, functional genomics, or whatever) to interpret and understand the
implications and how the organism develops and interacts with its environment. Along
this line, one must acknowledge the enormous debt we owe to animal-based research,
from mice, rats, guinea pigs, to sheep and other ruminants, to primates. Quite obvi-
ously, if one is to understand mammalian biology, one must study mammals.
Fourth, the community of scientists is vast, perhaps one of the truly global com-
munities. From genesis of the “big bang” of the new galaxy of investigation that
emerged at Oxford and Cambridge, a closely interconnected chain of small research
groups joined Britain in an “invisible college” that stretches across America,
Canada, and Australia. In contrast to neuroscience, cell and molecular biology, and
other fields, an examination of research centers of fetal–neonatal physiology dis-
closes that they are comparatively few. Some examples in no particular order
include in the USA, Cincinnati, Ohio, Denver, Colorado, Gainesville, Florida,
Madison, Wisconsin, Portland, Oregon, San Antonio, Texas, and Loma Linda, Los
Angeles, and San Francisco, California, London, Ontario, Canada, and Melbourne
and Sydney, Australia, and perhaps a few others. As is perhaps self evident, for the
most part, the rise and fall of these centers has depended upon a scientific and often
charismatic leader.
Fifth, in this regard mentorship by experienced scholars is vital to the develop-
ment and maturation of young scientists. A great mentor resembles being a parent,
“like motherhood, mentorship is forever.” It requires a commitment to listening,
helping with problem solving, mutual respect, trust, and assisting in every way pos-
sible the advancement of the mentee’s career. The handing down of information,
approaches, and values is encompassed to some under the rubric of tradition, and
bonding in a shared remembrance. By example and the enhancement of idealism,
one learns to spurn the path that is straight and smooth, and to pursue the scholarly
and contemplative life. With such dedication and commitment, one becomes a first-
rate scientist—and something more.
Sixth, cutting-edge science is fast moving, and requires collaboration of indi-
viduals with widely different training, experience, and expertise. Science has
become social with a distinctive culture. Because the disciplines of fetal and neona-
tal physiology have become broad and multifaceted, the former paradigms of the
“solo scientist” and “rugged individualism” are less applicable today. In addition to
developmental aspects of essentially every organ system, this includes vertical inte-
gration of the regulation of membrane trafficking, cytoskeletal dynamics, signal
transduction pathways and networks, protein–protein interactions, nuclear organi-
zation, gene regulation, cell division, cell death, and so forth. In the search for truth,
advantage must be taken of every opportunity to learn and to grow by interacting
with the most able minds available. In light of the major issues before us, we are
well advised to strengthen connections for interdisciplinary investigation with sci-
entists and institutions beyond our own universities and our borders. In terms of
22.5 What Lessons are to Be Learned? 493

interdisciplinary investigation, we need to include physical scientists, bioengineers,

mathematicians, information technologists, and others sharing ideas and working
together to answer the most challenging questions.
Along this line, is the meritocracy of science; that original and important ideas
and experimental studies originate from investigators in all quarters of the globe.
Fundamental is the importance of collaboration of basic scientists and physician–
scientists to advance the frontiers. As noted earlier, with the roots of biomedical
science in understanding natural phenomena, in view of the enormous complexity
of life, collaboration among those of different disciplines will be required for the
harvest is in implementing discoveries and that knowledge to effect solutions that
solve health problems to benefit individuals, and the world in which we live. In
terms of physician–scientists, this “endangered species” of individuals who can
bridge disciplines must be preserved in the exploration and search for increased
understanding and the answers to serious problems. Given the urgent need to con-
front major issues and problems of diseases of the fetus and newborn about which
we know little, our goal must be to advance the frontiers of basic research and the
search for truth, and its applicability to clinical medicine. Among great challenges
we face is to identify the most urgent research questions, and explore the most effec-
tive ways to attack and solve them. As in the past, it is most probable that individual
scholars or small groups will determine the most pressing questions, and seek their
solutions with success. As leaders and innovators, we must maintain a vision to
advance the frontiers of science and the good of humankind.
Seventh, it is clear that the practice of biomedical science and the quest to under-
stand how living organisms function has been transformed dramatically. To a great
extent technological advances drive scientific discovery and its application to health
care. In the present age, investigation is expensive with many technologies requiring
costly instruments best suited to a core laboratory (advanced multiphoton laser
scanning confocal microscopy and other imaging, DNA, RNA, and protein sequenc-
ing, mass spectrometry, oligonucleotide microarray analysis, and so forth). In large
part, the future of research and discovery in developmental physiology lies with
“next-generation” genomic, RNA, and protein analysis, advances in imaging, tissue
engineering, computational biology, mathematical modeling, and many other areas.
Eighth, concerns the issue of funding to support one’s studies. In the advance-
ment of science, one must appreciate the vital role fellowships, training grants,
scholarships, visiting professorships, sabbaticals, and other mechanisms play in pro-
moting first-rate science and scientists, and in obtaining a fresh viewpoint on life. By
most standards, the funds required to support these endeavors are relatively small,
however, their payoff and benefit for the good of humankind have been, and can be,
immense. An immensely complex business, in science one can never know enough.
As is appreciated, performing first-rate research is not inexpensive, and unpre-
dictability is the fabric of discovery. In much of present-day academia curiosity-
driven research is not looked upon favorably. Rather, grant applications must include
specifics of “preliminary studies” and the most minute details of the work already
having been done, with anticipated “relevance” to human health. Investigators
spend increasing amounts of time or fine-tuning their proposals, chasing
494 22 Epilogue

diminishing funding. Thus, their available time for “day dreaming” and creative
thinking is all but obliterated. Coupled with increasing University administrative
costs, and decreasing indirect costs, one wonders to what extent a young Barcroft,
Barron, Windle, or Dawes would be attracted to, and be able to survive in the cur-
rent environment. We must not forget that “if you think biomedical research is
expensive, try disease”.
Sobering in this regard, is an appreciation of the number of instances recounted
here in which an investigator, who later would become world-renowned, experi-
enced difficulty in gaining funding for their research, and/or presenting their work
at a national meeting, and/or getting their studies published. One is reminded of the
poignant words of Nobel Laureate Albert Szent-Györgyi (1893–1986), pioneer in
studying bioenergetics and oxidative phosphorylation, who, several times having
been denied grant support, decried the process of applying for external funding. In
reflecting upon his life experiences he wrote,
One … which has filled my whole scientific life with agony has been writing project pro-
posals … the situation is not … simple because research means going out into the unknown
with the hope of finding something new. … If you know in advance what you are going to
do, or … to find there, then it is not research at all … it is only a kind of honorable occupa-
tion … all my life [I] have had to fill up page after page of my … proposals with untruths.
There was no way out. The only alternative would have been to give up research.
(Szent-Györgyi 1971, pp. 1–2)

Szent-Györgyi also wrote further on the funding quagmire and frustrations faced
by young investigators (Szent-Györgyi 1974).
Nonetheless, I must confess that for the scientific officers and staff members of
the National Institutes of Health and other funding agencies who help to make all
of this possible, I have the highest regard. Over the many years, having served on
several different NIH study sections as well as other review groups (I received a
Postdoctoral Fellowship in 1964, and first R01 research grant in 1967, and during
the ensuing decades have been the recipient of a training grant, two program proj-
ect grants and other special awards). Some of the finest people I know have been
at the NICHD. I think and have wonderful memories of working with Duane
Alexander, Charlotte Catz, Joseph Hwang, Jehu Hunter, Michael Knecht, Norman
Kretchmer, Michael McClure, Samuel Moss, Tonse Raju, William Sadler, Sumner
Yaffe, and many others. Without exception these bright, dedicated, wonderful
people were and are committed to first-rate science and improving the health of
mothers and children. An historian could make a great contribution to life by
documenting the many, many contributions by those in this Pantheon of
administration.
Finally, in preparing this volume, I have been humbled and honored for the
opportunity to renew friendships with many of the leaders and “masters” of medi-
cine. A few of these include Sir Robert and Richard Boyd, John Challis, John
Clements, Richard Harding, “Mont” Liggins, Mildred Stahlman, Philip Sunshine,
David Walker, John Widdicombe, Maureen Young, and many, many others.
References 495

22.6 Conclusion

As we draw to a close, one of fisherman Geoffrey Dawes’ favorite authors was the
English man of letters Izaak Walton. In his 1653 work, The compleat angler. Or, the
contemplative man’s recreation, Walton wrote that, “… it is an art, and an art wor-
thy the knowledge and practice of a wise man,” “may be said to be so like the math-
ematics that it can never be fully learnt,” and “somewhat like poetry—men are to be
born so” (Walton 1983, pp. 155–163). In concluding his essay, Walton wrote,
My rod, and my line, my flote and my lead,
My hook, and my plummet, my whetstone and knife,
My Basket, my baits, both living and dead,
My net, and my meat, for that is the chief;
Then I must have thred and hairs great and smal,
With mine Angling purse, and so you have all.
(Walton 1983, p. 155)

And further,
Welcom pure thoughts, welcome ye silent groves,
These guests, these Courts, my soul most dearly loves;
Now the wing’d people of the Skie shall sing
My cheerful Anthems to the gladsome Spring;
A Pray’r book now shall be my looking glasse,
In which I will adore sweet vertues face.
Here dwell no hateful looks, no Pallace cares,
No broken vows dwell here, nor pale fac’d fears,
Then here I’l sit and sigh my hot loves folly,
And learn t’affect an holy melancholy.
And if contentment be a stranger, then
I’l nere look for it, but in heaven again.
(Walton 1983, pp. 162–163)

That described Geoffrey Dawes that we knew.

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Chapter 23
Bibliography of Geoffrey S. Dawes

1941
Dawes GS (1941) The vaso-dilator action of potassium. J Physiol (Lond) 99:224–238

1945
Bülbring E, Dawes GS (1945) A method for the assay of atropine substitutes on the salivary secre-
tion. J Pharmacol Exp Ther 84:177–183
Dawes GS (1945) The pharmacological action of benzamidines and benzamidoximes. J Pharmacol
Exp Ther 84:160–176
Ing HR, Dawes GS, Wajda I (1945) Synthetic substitutes for atropine. J Pharmacol Exp Ther
85:85–102

1946
Dawes GS (1946a) Amidines, guanidines, and adrenaline inactivation in the liver. Br J Pharmacol
Chemother 1:21–37
Dawes GS (1946b) Synthetic substitutes for quinidine. Br J Pharmacol Chemother 1:90–112
Dawes GS (1946c) Synthetic substitutes for quinidine. Br Med J 1:43–45

1947
Dawes GS (1947) Studies on veratrum alkaloids: VII. Receptor areas in the coronary arteries and
elsewhere as revealed by the use of veratridine. J Pharmacol Exp Ther 89:325–342

1949
Dawes GS, Feldberg W (1949) The causes of serum bradycardia. J Physiol (Lond) 108:362–364

1950
Dawes GS, Fastier FN (1950) Reflex actions of some isothiourea derivatives on circulation and
respiration. Br J Pharmacol Chemother 5:323–334

Abstracts are not included.

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to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5_23, © American Physiological Society 2013
500 23 Bibliography of Geoffrey S. Dawes

Dawes GS, Mott JC (1950) Circulatory and respiratory reflexes caused by aromatic guanidines.
Br J Pharmacol Chemother 5:65–76

1951
Dawes GS (1951) The reflexes from the heart and lungs caused by the veratrum alkaloids and other
compounds. Acta Physiol Scand 22:73–76
Dawes GS, Mott JC, Widdicombe JG (1951a) Respiratory and cardiovascular reflexes from the
heart and lungs. J Physiol (Lond) 115:258–291
Dawes GS, Mott JC, Widdicombe JG (1951b) The depressor action of the Veratrum alkaloids.
Br J Pharmacol Chemother 6:675–681

1952
Ardran GM, Dawes GS, Prichard MML, Reynolds SRM, Wyatt DG (1952) The effect of ventila-
tion of the foetal lungs upon the pulmonary circulation. J Physiol (Lond) 118:12–22
Dawes GS (1952a) Reflexes from the heart and lungs. Br Med Bull 8:324–330
Dawes GS (1952b) Experimental cardiac arrhythmias and quinidine-like drugs. Pharmacol Rev
4:43–84
Dawes GS, Mott JC, Widdicombe JG (1952) Chemoreceptor reflexes in the dog and the action of
phenyl diguanide. Arch Int Pharmacodyn Ther 90:203–222

1953
Dawes GS, Mott JC, Vane JR (1953a) The density flowmeter, a direct method for the measurement
of the rate of blood flow. J Physiol (Lond) 121:72–79
Dawes GS, Mott JC, Widdicombe JG, Wyatt DG (1953b) Changes in the lungs of the new-born
lamb. J Physiol (Lond) 121:141–162
Dawes GS, Widdicombe JG (1953) The afferent pathway of the Bezold reflex: the left vagal
branches in dogs. Br J Pharmacol Chemother 8:395–398

1954
Born GV, Dawes GS, Mott JC, Widdicombe JG (1954) Changes in the heart and lungs at birth.
Cold Spring Harb Symp Quant Biol 19:102–108
Dawes GS, Comroe JH Jr (1954) Chemoreflexes from the heart and lungs. Physiol Rev
34:167–201
Dawes GS, Mott JC, Widdicombe JG (1954) The foetal circulation in the lamb. J Physiol (Lond)
126:563–587

1955
Born GV, Dawes GS, Mott JC (1955a) The viability of premature lambs. J Physiol (Lond)
130:191–212
Born GV, Dawes GS, Mott JC, Rennick BR (1955b) The relief of central cyanosis caused by pul-
monary arterio-venous shunts by construction of an artificial ductus arteriosus. J Physiol
(Lond) 130:167–190
Dawes GS (1955–1956) Physiological effects of anoxia in the foetal and newborn lamb. Lect Sci
Basis Med 5:53–66
Dawes GS, Mott JC, Widdicombe JG (1955a) The cardiac murmur from the patent ductus arterio-
sus in newborn lambs. J Physiol (Lond) 128:344–360
Dawes GS, Mott JC, Widdicombe JG (1955b) The patency of the ductus arteriosus in newborn
lambs and its physiological consequences. J Physiol (Lond) 128:361–383
23 Bibliography of Geoffrey S. Dawes 501

Dawes GS, Mott JC, Widdicombe JG (1955c) Closure of the foramen ovale in newborn lambs.
J Physiol (Lond) 128:384–395
Dawes GS, Parry HB (1955) Correspondence. Uterine ischaemia and pre-eclampsia. Br Med J
2:849

1956
Born GV, Dawes GS, Mott JC (1956a) Oxygen lack and autonomic nervous control of the foetal
circulation in the lamb. J Physiol (Lond) 134:149–166
Born GV, Dawes GS, Mott JC, Rennick BR (1956b) The constriction of the ductus arteriosus
caused by oxygen and by asphyxia in newborn lambs. J Physiol (Lond) 132:304–342
Dawes GS, Mott JC, Rennick BR (1956) Some effects of adrenaline, noradrenaline and acetylcho-
line on the foetal circulation in the lamb. J Physiol (Lond) 134:139–148
Dawes GS, Vane JR (1956) The refractory period of atria isolated from mammalian hearts.
J Physiol (Lond) 132:611–629

1957
Acheson GH, Dawes GS, Mott JC (1957) Oxygen consumption and the arterial oxygen saturation
in foetal and new-born lambs. J Physiol (Lond) 135:623–643
Dawes GS, Handler JJ, Mott JC (1957) Some cardiovascular responses in foetal, new-born and
adult rabbits. J Physiol (Lond) 139:123–136

1958
Amoroso EC, Dawes GS, Mott JC (1958) Patency of the ductus arteriosus in the newborn calf and
foal. Br Heart J 20:92–96
Dawes GS (1958a) The course of the circulation in the newborn infant. Triangle 3:271–277
Dawes GS (1958b) Changes in the circulation at birth and the effects of asphyxia. In: Gairdner D
(ed) Recent advances in paediatrics, 2nd edn. J. & A Churchill Ltd., London, pp 1–49

1959
Cross KW, Dawes GS, Mott JC (1959) Anoxia, oxygen consumption and cardiac output in new-
born lambs and adult sheep. J Physiol (Lond) 146:316–343
Dawes GS (1959a) Some respiratory and cardiovascular problems after birth. Arch Dis Child
34:281–291
Dawes GS (1959b) Reflexes originating in the pulmonary circulation. In: Adams WR, Weith I
(eds) Pulmonary circulation. Grune & Stratton, New York, NY, pp 57–61
Dawes GS (1959c) The pulmonary circulation after birth. In: Adams WR, Weith I (eds) Pulmonary
circulation. Grune & Stratton, New York, NY, pp 199–203
Dawes GS, Mott JC (1959a) Reflex respiratory activity in the new-born rabbit. J Physiol (Lond)
145:85–97
Dawes GS, Mott JC (1959b) The increase in oxygen consumption of the lamb after birth. J Physiol
(Lond) 146:295–315
Dawes GS, Mott JC, Shelley HJ (1959) The importance of cardiac glycogen for the maintenance
of life in foetal lambs and newborn animals during anoxia. J Physiol (Lond) 146:516–538

1960
Dawes GS (1960) Anoxia and survival after birth. Proc R Soc Med 53:1039–1041
Dawes GS, Jacobson HN, Mott JC, Shelley HJ (1960) Some observations on foetal and new-born
rhesus monkeys. J Physiol (Lond) 152:271–298
502 23 Bibliography of Geoffrey S. Dawes

1961
Dawes GS (1961) Changes in the circulation at birth. Br Med Bull 17:148–153

1962
Dawes GS (1962a) K nekterym otazkam fysiologie plodu a novorozence [On some problems in the
physiology of the fetus and neonate.]. Cesk Fysiol 11:8–17
Dawes GS (1962b) The umbilical circulation. Am J Obstet Gynecol 84:1634–1648
Dawes GS (1962c) Adrenaline and the foetal circulation. Br Med J 1:636–637
Dawes GS (1962d) Placental development and umbilical blood flow. J Obstet Gynaecol Br Emp
69:815–817
Dawes GS (1962e) Vasodilatation in the unexpanded foetal lung. Med Thorac 19:345–353
Dawes GS, Mott JC (1962) The vascular tone of the foetal lung. J Physiol (Lond) 164:465–477
Shelley HJ, Dawes GS (1962) Fate of fructose in the newly delivered foetal lamb. Nature
194:296–297

1963
Adamsons KR Jr, Behrman GS, Dawes MJ, Dawkins LSJ, Ross BB (1963) The treatment of aci-
dosis with alkali and glucose during asphyxia in foetal rhesus monkeys. J Physiol (Lond)
169:679–689
Dawes GS (1963) Circulatory adjustments in the newborn. Heart Bull 12:17–19
Dawes GS, Jacobson HN, Mott JC, Shelley HJ, Stafford A (1963a) The treatment of asphyxiated,
mature foetal lambs and rhesus monkeys with intravenous glucose and sodium carbonate.
J Physiol (Lond) 169:167–184
Dawes GS, Mestyan G (1963) Changes in the oxygen consumption of new-born guinea-pigs and
rabbits on exposure to cold. J Physiol (Lond) 168:22–42
Dawes GS, Mott JC, Shelley HJ (1963b) Hypothermia in resuscitation of the newborn. Br Med J
2:1266
Dawes GS, Mott JC, Shelley HJ, Stafford A (1963c) The prolongation of survival time in asphyxi-
ated immature foetal lambs. J Physiol (Lond) 168:43–64

1964
Adamsons KR Jr, Behrman GS, Dawes LSJ, Koford C (1964) Resuscitation by positive pressure
ventilation and Tris-hydroxymethylaminomethane of rhesus monkeys asphyxiated at birth.
J Pediatr 65:807–818
Cassin S, Dawes GS, Mott JC, Ross BB, Strang LB (1964a) The vascular resistance of the foetal
and newly ventilated lung of the lamb. J Physiol (Lond) 171:61–79
Cassin S, Dawes GS, Ross BB (1964b) Pulmonary blood flow and vascular resistance in immature
foetal lambs. J Physiol (Lond) 171:80–89
Cross KW, Dawes GS, Hyman A, Mott JC (1964) Hyperbaric oxygen and intermittent positive-
pressure ventilation in resuscitation of asphyxiated newborn rabbits. Lancet 2:560–562
Dawes GS (1964a) Physiological changes in the circulation after birth. In: Fishman AP, Richards
DW (eds) Circulation of the blood, men and ideas. Oxford University Press, New York, NY,
pp 743–816
Dawes GS (1964b) Obituaries. Dr. R.S. Creed. Nature 204:20–21
Dawes GS, Cross KW (1964) Hyperbaric oxygen in resuscitation of the newborn. Lancet 2:910
Dawes GS, Hibbard E, Windle WF (1964) The effect of alkali and glucose infusion on permanent
brain damage in rhesus monkeys asphyxiated at birth. J Pediatr 65:801–806
Dawes GS, Mott JC (1964) Changes in O2 distribution and consumption in foetal lambs with varia-
tions in umbilical blood flow. J Physiol (Lond) 170:524–540
23 Bibliography of Geoffrey S. Dawes 503

1965
Colebatch HJ, Dawes GS, Goodwin JW, Nadeau RA (1965) The nervous control of the circulation
in the foetal and newly expanded lungs of the lamb. J Physiol (Lond) 178:544–562
Dawes GS (1965a) Changes in the circulation at birth. Anesthesiology 26:522–530
Dawes GS (1965b) The amniotic fluid. Dev Med Child Neurol 7:201–202
Dawes GS (1965c) Prospects in prenatal physiology, diagnosis, and treatment. Pediatrics
35:731–732
Dawes GS (1965d) Cardiovascular pulmonary reflexes and possible relationship to mechanisms of
sudden death. In: Benditt EP, Burnett WM (eds) Sudden death in infants. Proceedings of the
conference on causes of sudden death in infants, September 1963, Seattle, Washington. R.J.
Wedgwood. U.S. Department of Health, Education, and Welfare Public Health Service,
National Institutes of Health, Bethesda, MD, pp 101–109
Dawes GS (1965e) The circulation, respiration and general metabolism of the newborn. In:
Gairdner D (ed) Recent advances in paediatrics, 3rd edn. Churchill, London, pp 1–35
Dawes GS, Parry HB (1965) Premature delivery and survival in lambs. Nature 207:330

1966
Campbell AG, Cross KW, Dawes GS, Hyman AI (1966a) A comparison of air and O2, in a hyper-
baric chamber or by positive pressure ventilation, in the resuscitation of newborn rabbits.
J Pediatr 68:153–163
Campbell AG, Dawes GS, Fishman AP, Hyman AI, James GB (1966b) The oxygen consumption
of the placenta and foetal membranes in the sheep. J Physiol (Lond) 182:439–464
Daniel SS, Dawes GS, James LS, Ross BB (1966a) Analeptics and the resuscitation of asphyxiated
monkeys. Br Med J 2:562–563
Daniel SS, Dawes GS, James LS, Ross BB, Windle WF (1966b) Hypothermia and the resuscita-
tion of asphyxiated fetal rhesus monkeys. J Pediatr 68:45–53
Dawes GS (1966a) Pulmonary circulation in the foetus and new-born. Br Med Bull 22:61–65
Dawes GS (1966b) Value of animal experiments in cerebral palsy. Dev Med Child Neurol
8:336–337
Dawes GS (1966c) Treatment of asphyxia neonatorum. Lancet 1:1214–1215
Dawes GS (1966d) The first breath. Proc R Soc Med 59:508
Dawes GS (1966e) Changes in the circulation at birth. In: Cassels DE (ed) The heart and circula-
tion in the newborn and infant. Grune & Stratton, New York, NY, pp 74–79
Dawes GS, Tooley WH, Behrman RE (1966) Alkali therapy – pro or con. J Pediatr 69:1170

1967
Campbell AG, Cockburn F, Dawes GS, Milligan JE (1967a) Pulmonary vasoconstriction in
asphyxia during cross-circulation between twin foetal lambs. J Physiol (Lond) 192:111–121
Campbell AG, Dawes GS, Fishman AP, Hyman AI (1967b) Regional redistribution of blood flow
in the mature fetal lamb. Circ Res 21:229–235
Campbell AG, Dawes GS, Fishman AP, Hyman AI (1967c) Pulmonary vasoconstriction and
changes in heart rate during asphyxia in immature foetal lambs. J Physiol (Lond) 192:93–110
Cross KW, Dawes GS (1967) Apnoea in hyperbaric oxygen. Lancet 289:47–48
Dawes GS (1967a) New views on O2 transfer across the placenta. Sci Basis Med Annu Rev
1967:74–89
Dawes GS (1967b) Oxygen consumption of the placental and foetal membranes in the sheep. In:
de Reuck AVS, Porter R (eds) Development of the lung. A Ciba Foundation symposium. Little,
Brown and Company, Boston, MA, pp 297–311
504 23 Bibliography of Geoffrey S. Dawes

1968
Campbell AG, Dawes GS, Fishman AP, Hyman AI, Perks AM (1968) The release of a bradykinin-
like pulmonary vasodilator substance in foetal and new-born lambs. J Physiol (Lond)
195:83–96
Dawes GS (1968a) Sudden death in babies: physiology of the fetus and newborn. Am J Cardiol
22:469–478
Dawes GS (1968b) Foetal blood-gas homeostasis during development. Proc R Soc Med
61:1227–1231
Dawes GS (1968c) Foetal and neonatal physiology; a comparative study of the changes at birth.
Year Book Medical Publishers, Chicago, IL
Dawes GS (1968d) Placental oxygen consumption. In: Wynn RM (ed) Fetal homeostasis.
Appleton-Century-Crofts, New York, NY, pp 142–151
Dawes GS (1968e) Chairman’s introduction. Proc R Soc Med 61:1187
Dawes GS (1968f) Chairman’s summing-up. Proc R Soc Med 61:1253–1254
Dawes GS, Lewis BV, Milligan JE, Roach MR, Talner NS (1968) Vasomotor responses in the hind
limbs of foetal and new-born lambs to asphyxia and aortic chemoreceptor stimulation. J Physiol
(Lond) 195:55–81

1969
Cockburn F, Daniel SS, Dawes GS, James LS, Myers RE, Nienann W, Rodriguez de Curet H, Ross
BB (1969) The effect of pentobarbital anesthesia on resuscitation and brain damage in fetal
rhesus monkeys asphyxiated on delivery. J Pediatr 75:281–291
Dawes GS (1969a) Introduction. In: Wolstenholme GEW, O’Connor M (eds) Foetal autonomy.
Ciba Foundation symposium. Churchill, London
Dawes GS (1969b) Chairman’s opening remarks. In: Wolstenholme GEW, O’Connor M (eds)
Foetal autonomy. A Ciba Foundation symposium. J. &A. Churchill Ltd., London, p 1
Dawes GS (1969c) Foetal blood gas homeostasis. In: Wolstenholme GEW, O’Connor M (eds)
Foetal autonomy. A Ciba Foundation symposium. J. &A. Churchill Ltd., London, pp 162–175
Dawes GS (1969d) Chairman’s closing remarks. In: Wolstenholme GEW, O’Connor M (eds)
Foetal autonomy. A Ciba Foundation symposium. J. &A. Churchill Ltd., London, pp 315–316
Dawes GS (1969e) Control of the pulmonary circulation in the fetus and newborn. In: Fishman AP,
Hecht HH (eds) The pulmonary circulation and interstitial space. University of Chicago Press,
Chicago, IL, pp 293–304
Dawes GS, Duncan SL, Lewis BV, Merlet CL, Owen-Thomas JB, Reeves JT (1969a) Hypoxaemia
and aortic chemoreceptor function in foetal lambs. J Physiol (Lond) 201:105–116
Dawes GS, Duncan SL, Lewis BV, Merlet CL, Owen-Thomas JB, Reeves JT (1969b) Cyanide
stimulation of the systemic arterial chemoreceptors in foetal lambs. J Physiol (Lond)
201:117–128

1971
Baillie P, Dawes GS, Merlet CL, Richards R (1971) Maternal hyperventilation and foetal hypocap-
nia in sheep. J Physiol (Lond) 218:635–650
Dawes GS (1971) Gas exchange between mother and foetus and placental design. In: Gevers RH,
Ruys JH (eds) Physiology and pathology in the perinatal period. Springer-Verlag New York
Inc., New York, NY, pp 3–12
23 Bibliography of Geoffrey S. Dawes 505

1972
Dawes GS (1972) Fetal monitoring, fetal physiology and fetal breathing in-utero. J Obstet
Gynaecol Br Commonw 79:281–283
Dawes GS, Fox HE, Leduc BM, Liggins GC, Richards RT (1972a) Respiratory movements and
rapid eye movement sleep in the foetal lamb. J Physiol (Lond) 220:119–143
Dawes GS, Fox HE, Richards RT (1972b) Variations in asphyxial gasping with fetal age in lambs
and guinea-pigs. Q J Exp Physiol Cogn Med Sci 57:131–138
Johnson P, Dawes GS, Robinson JS (1972) Maintenance of breathing in newborn lamb. Arch Dis
Child 47:151

1973
Boddy K, Dawes GS, Robinson JS (1973) A 24-hour rhythm in the foetus. In: Foetal and neonatal
physiology. Proceedings of the Sir Joseph Barcroft Centenary Symposium held at the
Physiological Laboratory, Cambridge, 25 to 27 July 1972. At the University Press, Cambridge,
pp 63–66
Brady JP, Cornetta WJ III, Shannon DC, Hogan GR, Dawes GS, Steinschneider A, Talbot NB
(1973) Weekly clinicopathological exercises. Case 31-1973 sudden death in an infant. N Eng J
Med 289:261–265
Dawes GS (1973a) Antibiotic levels in tissue fluid. Br Med J 1:798
Dawes GS (1973b) Revolutions and cyclical rhythms in prenatal life: fetal respiratory movements
rediscovered. Pediatrics 51:965–971
Dawes GS (1973c) The distribution and actions of drugs on the foetus in utero. Br J Anaesth
45(Suppl):766–769
Dawes GS (1973d) Breathing and rapid-eye-movement sleep before birth. In: Foetal and neonatal
physiology. Proceedings of the Sir Joseph Barcroft Centenary Symposium held at the
Physiological Laboratory, Cambridge, 25 to 27 July 1972. At the University Press, Cambridge,
pp 49–62

1974
Boddy K, Dawes GS, Fisher R, Pinter S, Robinson JS (1974a) Foetal respiratory movements,
electrocortical and cardiovascular responses to hypoxaemia and hypercapnia in sheep. J Physiol
(Lond) 243:599–618
Boddy K, Dawes GS, Robinson J (1974b) Intrauterine fetal breathing movements. In: Gluck L (ed)
Modern perinatal medicine. Year Book Medical Publishers, Inc., Chicago, IL, pp 381–389
Dawes GS (1974a) Fetal circulation and breathing. Clin Obstet Gynaecol 1:139–149
Dawes GS (1974b) Breathing before birth in animals and man. An essay in developmental medi-
cine. N Engl J Med 290:557–559
Dawes GS (1974c) Introduction. In: Elliott K, Knight J (eds) Size at birth. Ciba Foundation sym-
posium. 27(ns). Elsevier, Amsterdam, pp 1–2

1975
Boddy K, Dawes GS (1975) Fetal breathing. Br Med Bull 31:3–7
Dawes GS (1975) Concluding comment apropos of physiology. In: Symposium on Development
of Upper Respiratory Anatomy and Function (1974; National Institutes of Health) Development
of upper respiratory anatomy and function: implications for sudden infant death syndrome. For
sale by the Supt. Of Docs., U.S. Govt. Print. Off., Washington, DC, pp 266–269
506 23 Bibliography of Geoffrey S. Dawes

1976
Boddy K, Dawes GS, Fisher RL, Pinter S, Robinson JS (1976) The effects of pentobarbitone and
pethidine on foetal breathing movements in sheep. Br J Pharmacol 57:311–317
Boyce ES, Dawes GS, Gough JD, Poore ER (1976) Doppler ultrasound method for detecting
human fetal breathing in utero. Br Med J 2:17–18
Dawes GS (1976a) The physiological determinants of fetal growth. J Reprod Fertil 47:183–187
Dawes GS (1976b) Annotation [of Apgar Score]. Landmarks in Perinatology/Neonatology. Ross
Laboratories, Columbus, OH
Dawes GS, Robinson JS (1976) Rhythmic phenomena in prenatal life. Prog Brain Res
45:383–389
Patrick JE, Dalton KJ, Dawes GS (1976) Breathing patterns before death in fetal lambs. Am J
Obstet Gynecol 125:73–78
Wood WG, Pearce K, Clegg JB, Weatherall DJ, Robinson JS, Thorburn GD, Dawes GS (1976)
Switch from foetal to adult haemoglobin synthesis in normal and hypophysectomised sheep.
Nature 264:799–801

1977
Dalton KJ, Dawes GS, Patrick JE (1977) Diurnal, respiratory, and other rhythms of fetal heart rate
in lambs. Am J Obstet Gynecol 127:414–424
Dawes GS (1977a) Fetal breathing. Am Rev Respir Dis 115:5–10
Dawes GS (1977b) Fetal breathing movements and sleep in sheep. Ann Rech Vet 8:413–417
Dawes GS (1977c) Introduction: a historical perspective. In: The fetus and birth. Ciba Foundation
symposium. 47(ns). Elsevier, Amsterdam, pp 1–4
Wood WG, Clegg JB, Weatherall DJ, Nash J, Robinson JS, Thorburn GD, Dawes GS (1977)
Haemoglobin switching during development in normal and hypophysectomised fetal sheep.
Ann Rech Vet 8:379–383

1978
Chapman RL, Dawes GS (1978) Intermittent breathing before death in fetal lambs. Am J Obstet
Gynecol 131:894–898
Dawes GS (1978a) Prostaglandin physiology in the fetus. Adv Prostaglandin Thromboxane Res
4:387–393
Dawes GS (1978b) Natural cyclical changes and the effects of hypoxia in fetal sheep. In: Longo
LD, Reneau DD (eds) Fetal and newborn cardiovascular physiology. Garland STPM Press,
New York, NY, pp 223–229

1979
Dawes GS (1979) Fetal breathing movements, a natural history in animals and man. Contrib
Gynecol Obstet 6:62–65

1980
Chapman RL, Dawes GS, Rurak DW, Wilds PL (1980) Breathing movements in fetal lambs and
the effect of hypercapnia. J Physiol (Lond) 302:19–29
Dawes GS (1980) The development of breathing. In: Widdowson EM (ed) Studies in perinatal
physiology. Pitman Medical, Tunbridge Wells, pp 4–6
Dawes GS, Johnston BM, Walker DW (1980) Relationship of arterial pressure and heart rate in
fetal, new-born, and adult sheep. J Physiol (Lond) 309:405–417
Thaler I, Goodman JD, Dawes GS (1980) Effects of maternal cigarette smoking on fetal breathing
and fetal movements. Am J Obstet Gynecol 138:282–287
23 Bibliography of Geoffrey S. Dawes 507

Visser GH, Goodman JD, Dawes GS (1980) Problem with ultrasonic fetal heart rate monitor.
Lancet 1:707–708

1981
Dawes GS (1981) Introduction. In: The fetus and independent life. Ciba Foundation symposium
86. Pitman, London, pp 1–4
Dawes GS, Henderson-Smart DJ (1981) Breathing before and after birth. Int Rev Physiol
23:75–110
Dawes GS, Visser GH, Goodman JD, Levine DH (1981a) Numerical analysis of the human fetal
heart rate: modulation by breathing and movement. Am J Obstet Gynecol 140:535–544
Dawes GS, Visser GH, Goodman JD, Redman CW (1981b) Numerical analysis of the human fetal
heart rate: the quality of ultrasound records. Am J Obstet Gynecol 141:43–52
Dawes GS, Walker DW, Johnston BM (1981c) The central control of fetal breathing and move-
ments. In: The fetus and independent life. Ciba Foundation symposium 86. Pitman, London,
pp 295–307
Natale R, Clewlow F, Dawes GS (1981) Measurement of fetal forelimb movements in the lamb in
utero. Am J Obstet Gynecol 140:545–551
Visser GH, Dawes GS, Redman CW (1981a) Numerical analysis of the normal human antenatal
fetal heart rate. Br J Obstet Gynaecol 88:792–802
Visser GH, Goodman JD, Levine DH, Dawes GS (1981b) Micturition and the heart period cycle in
the human fetus. Br J Obstet Gynaecol 88:803–805

1982
Dawes GS, Houghton CR, Redman CW (1982a) Baseline in human fetal heart-rate records. Br J
Obstet Gynaecol 89:270–275
Dawes GS, Houghton CR, Redman CW, Visser GH (1982b) Pattern of the normal human fetal
heart rate. Br J Obstet Gynaecol 89:276–284
Dawes GS, Gardner WN, Johnston BM, Walker DW (1982c) Effects of hypercapnia on tracheal
pressure, diaphragm and intercostal electromyograms in unanaesthetized fetal lambs. J Physiol
(Lond) 326:461–474
Greene KR, Dawes GS, Lilja H, Rosén KG (1982) Changes in the ST waveform of the fetal lamb
electrocardiogram with hypoxemia. Am J Obstet Gynecol 144:950–958
Lawson G, Dawes GS, Redman CW (1982) A comparison of two fetal heart rate ultrasound detec-
tor systems. Am J Obstet Gynecol 143:840–841
Visser GH, Goodman JD, Levine DH, Dawes GS (1982) Diurnal and other cyclic variations in
human fetal heart rate near term. Am J Obstet Gynecol 142:535–544

1983
Blanco CE, Dawes GS, Walker DW (1983a) Effect of hypoxia on polysynaptic hind-limb reflexes
of unanaesthetized fetal and new-born lambs. J Physiol (Lond) 339:453–466
Blanco CE, Dawes GS, Walker DW (1983b) Effects of hypoxia on polysynaptic hind-limb reflexes
in new-born lambs before and after carotid denervation. J Physiol (Lond) 339:467–474
Clewlow F, Dawes GS, Johnston BM, Walker DW (1983) Changes in breathing, electrocortical
and muscle activity in unanaesthetized fetal lambs with age. J Physiol (Lond) 341:463–476
Dalton KJ, Dawes GS, Patrick JE (1983) The autonomic nervous system and fetal heart rate vari-
ability. Am J Obstet Gynecol 146:456–462
Dawes GS, Gardner WN, Johnston BM, Walker DW (1983) Breathing in fetal lambs: the effect of
brain stem section. J Physiol (Lond) 335:535–553
Henson GL, Dawes GS, Redman CW (1983) Antenatal fetal heart-rate variability in relation to
fetal acid-base status at caesarean section. Br J Obstet Gynaecol 90:516–521
508 23 Bibliography of Geoffrey S. Dawes

Lawson GW, Belcher R, Dawes GS, Redman CW (1983) A comparison of ultrasound (with auto-
correlation) and direct electrocardiogram fetal heart rate detector systems. Am J Obstet
Gynecol 147:721–722
Visser GH, Zeelenberg HJ, de Vries JI, Dawes GS (1983) External physical stimulation of the
human fetus during episodes of low heart rate variation. Am J Obstet Gynecol 145:579–584
Wickham PJD, Dawes GS, Belcher R (1983) Development of methods for quantitative analysis of
the fetal heart rate. J Biomed Eng 5:302–308

1984
Blanco CE, Dawes GS, Hanson MA, McCooke HB (1984) The response to hypoxia of arterial
chemoreceptors in fetal sheep and new-born lambs. J Physiol (Lond) 351:25–37
Dawes GS (1984a) The central control of fetal breathing and skeletal muscle movements. J Physiol
(Lond) 346:1–18
Dawes GS (1984b) Fetal physiology and behaviour: changing direction 1954-1983. J Dev Physiol
6:259–265
Goodman JD, Visser GH, Dawes GS (1984) Effects of maternal cigarette smoking on fetal trunk
movements, fetal breathing movements and the fetal heart rate. Br J Obstet Gynaecol
91:657–661
Henson G, Dawes GS, Redman CW (1984) Characterization of the reduced heart rate variation in
growth-retarded fetuses. Br J Obstet Gynaecol 91:751–755
Lawson GW, Dawes GS, Redman C (1984) Analysis of fetal heart rate on-line at 32 weeks gesta-
tion. Br J Obstet Gynaecol 91:542–550

1985
Blanco CE, Dawes GS, Hanson MA, McCooke HB (1985) Studies of carotid baroreceptor affer-
ents in fetal and newborn lambs. In: Jones CT, Nathanielsz PW (eds) The physiological devel-
opment of the fetus and newborn. Academic, London, pp 595–598
Clewlow F, Dawes GS (1985) The association between cardiac accelerations and movements in
fetal sheep. J Dev Physiol 7:281–287
Dawes GS (1985a) Fetal heart rate monitoring. In: Jones CT, Nathanielsz PW (eds) The physiolog-
ical development of the fetus and newborn. Academic, London, pp 695–698
Dawes GS (1985b) Perinatal physiology, the past, present and future. In: Jones CT, Nathanielsz
PW (eds) The physiological development of the fetus and newborn. Academic, London,
pp 827–830
Dawes GS (1985c) Why fetal physiology? In: Rooth G, Saugstad OD (eds) The roots of perinatal
medicine. Georg Thieme Verlag, Stuttgart, pp 26–30
Dawes GS, Redman CW, Smith JH (1985) Improvements in the registration and analysis of fetal
heart rate records at the bedside. Br J Obstet Gynaecol 92:317–325
Hofmeyr GJ, Bamford OS, Dawes GS, Parkes MJ (1985a) High frequency heart rate variability in
the fetal lamb. In: Jones CT, Nathanielsz PW (eds) The physiological development of the fetus
and newborn. Academic, London, pp 439–444
Hofmeyr GJ, Bamford OS, Gianopoulos JG, Parkes MJ, Dawes GS (1985b) The partial association
of uterine contractions with changes in electrocortical activity, breathing, and PaO2 in the fetal
lamb: effects of brain stem section. Am J Obstet Gynecol 152:905–910
Jensen A, Bamford OS, Dawes GS, Hofmeyr GJ, Parkes MJ (1985) Changes in organ blood flow
between high and low voltage electrocortical activity and during isocapnic hypoxia in intact
and brain stem transected fetal lambs. In: Jones CT, Nathanielsz PW (eds) The physiological
development of the fetus and newborn. Academic, London, pp 605–610
Olsen GD, Dawes GS (1985) Morphine-induced depression and stimulation of breathing move-
ments in the fetal lamb. In: Jones CT, Nathanielsz PW (eds) The physiological development of
the fetus and newborn. Academic, London, pp 633–638
23 Bibliography of Geoffrey S. Dawes 509

Roebuck MM, Castle BM, Vojcek L, Weingold A, Dawes GS, Turnbull AC (1985) The effect of
nifedipine administration on the fetus and the myometrium of pregnant sheep during oxytocin
induced contractions. In: Jones CT, Nathanielsz PW (eds) The physiological development of
the fetus and newborn. Academic, London, pp 499–503

1986
Bamford OS, Dawes GS, Denny R, Ward RA (1986a) Effects of the alpha 2-adrenergic agonist
clonidine and its antagonist idazoxan on the fetal lamb. J Physiol (Lond) 381:29–37
Bamford OS, Dawes GS, Hanson MA, Ward RA (1986b) The effects of doxapram on breathing,
heart rate and blood pressure in fetal lambs. Respir Physiol 66:387–396
Bamford OS, Dawes GS, Ward RA (1986c) Effects of apomorphine and haloperidol in fetal lambs.
J Physiol (Lond) 377:37–47
Dawes GS (1986a) An appreciation of Dr. Raymond Ing F.R.S., founding secretary of the British
Journal of Pharmacology. Br J Pharmacol 87:461
Dawes GS (1986b) The central nervous control of fetal behaviour. Eur J Obstet Gynecol Reprod
Biol 21:341–346
Dawes GS (1986c) The rediscovery of fetal breathing movements and its consequences. In:
Johnston BM, Gluckman PD (eds) Respiratory control and lung development in the fetus and
newborn. Perinatology Press, Ithaca, NY, pp 209–222
Jensen A, Bamford OS, Dawes GS, Hofmeyr G, Parkes MJ (1986) Changes in organ blood flow
between high and low voltage electrocortical activity in fetal sheep. J Dev Physiol 8:187–194

1987
Dawes GS, Redman CW (1987) Fetal heart rate monitoring. Am J Obstet Gynecol 157:513–514
Smith JH, Dawes GS, Redman CW (1987) Low human fetal heart rate variation in normal preg-
nancy. Br J Obstet Gynaecol 94:656–664
Spencer JA, Belcher R, Dawes GS (1987) The influence of signal loss on the comparison between
computer analyses of the fetal heart rate in labour using pulsed Doppler ultrasound (with auto-
correlation) and simultaneous scalp electrocardiogram. Eur J Obstet Gynecol Reprod Biol
25:29–34

1988
Blanco CE, Dawes GS, Hanson MA, McCooke HB (1988) Carotid baroreceptors in fetal and new-
born sheep. Pediatr Res 24:342–346
Dawes GS (1988) The 1987 James A. F. Stevenson memorial lecture. The development of fetal
behavioural patterns. Can J Physiol Pharmacol 66:541–548
Pello LC, Dawes GS, Smith J, Redman CW (1988) Screening of the fetal heart rate in early labour.
Br J Obstet Gynaecol 95:1128–1136
Smith JH, Anand KJ, Cotes PM, Dawes GS, Harkness RA, Howlett TA, Rees LH, Redman CW
(1988) Antenatal fetal heart rate variation in relation to the respiratory and metabolic status of
the compromised human fetus. Br J Obstet Gynaecol 95:980–989
Wheble AM, Dawes GS, Gillmer MDG, Sykes GS (1988) A double blind quantitative study of the
effects of meptazinol and pethidine on the fetal heart rate in labour. J Obstet Gynaecol
8:248–252

1989
Dawes GS (1989) Introduction Mont Liggins on birth, the fetal lung and the Weddell seal. In:
Gluckman PD, Johnston BM, Nathanielsz PW (eds) Research in perinatal medicine (VIII).
Advances in fetal physiology: reviews in honor of G.C. Liggins. Perinatology Press, Ithaca,
NY, pp 1–12
510 23 Bibliography of Geoffrey S. Dawes

1990
Bamford OS, Dawes GS (1990) Hypoxia and electrocortical activity in the fetal lamb: effects of
brainstem transection and chemoreceptor denervation. J Dev Physiol 13:271–276
Dawes GS (1990a) Correspondence. Embryo research. Nature 346:212
Dawes GS (1990b) Fetal autonomy and adaptation. In: Dawes GS, Borruto F, Zacutti A, Zacutti A
Jr (eds) Fetal autonomy and adaptation. Wiley, Chichester, NY, pp 1–4
Dawes GS, Borruto F, Zacutti A, Zacutti A Jr (eds) (1990a) Fetal autonomy and adaptation. Wiley,
Chichester, NY
Dawes GS, Moulden M, Redman CW (1990b) Limitations of antenatal fetal heart rate monitors.
Am J Obstet Gynecol 162:170–173
Dawes GS, Moulden M, Redman CW (1990c) Criteria for the design of fetal heart rate analysis
systems. Int J Biomed Comput 25:287–294

1991
Dawes GS (1991) Computerised analysis of the fetal heart rate. Eur J Obstet Gynecol Reprod Biol
42(Suppl):S5–S8
Dawes GS, Moulden M, Redman CW (1991a) The advantages of computerized fetal heart rate
analysis. J Perinat Med 19:39–45
Dawes GS, Moulden M, Redman CW (1991b) System 8000: computerized antenatal FHR analy-
sis. J Perinat Med 19:47–51
Dawes GS, Rosevear SK, Pello LC, Moulden M, Redman CW (1991c) Computerized analysis of
episodic changes in fetal heart rate variation in early labor. Am J Obstet Gynecol
165:618–624
Pello LC, Rosevear SK, Dawes GS, Moulden M, Redman CW (1991) Computerized fetal heart
rate analysis in labor. Obstet Gynecol 78:602–610
Street P, Dawes GS, Moulden M, Redman CW (1991) Short-term variation in abnormal antenatal
fetal heart rate records. Am J Obstet Gynecol 165:515–523

1992
Dawes GS (1992) A new look at the foramen ovale. Ultrasound Obstet Gynecol 2:384–385
Dawes GS, Lobb M, Moulden M, Redman CW, Wheeler T (1992a) Antenatal cardiotocogram
quality and interpretation using computers. Br J Obstet Gynaecol 99:791–797
Dawes GS, Moulden M, Redman CW (1992b) Short-term fetal heart rate variation, decelerations,
and umbilical flow velocity waveforms before labor. Obstet Gynecol 80:673–678
Dawes GS, Moulden M, Sheil O, Redman CW (1992c) Approximate entropy, a statistic of regular-
ity, applied to fetal heart rate data before and during labor. Obstet Gynecol 80:763–768
Dawes GS, Redman CW (1992) Automated analysis of the FHR: evaluation? Am J Obstet Gynecol
167:1912–1914
Economides DL, Selinger M, Ferguson J, Bowell PJ, Dawes GS, Mackenzie IZ (1992)
Computerized measurement of heart rate variation in fetal anemia caused by rhesus alloim-
munization. Am J Obstet Gynecol 167:689–693

1993
Dawes GS (1993) The fetal ECG: accuracy of measurements. Br J Obstet Gynaecol 100(Suppl
9):15–17
Dawes GS, Lobb MO, Mandruzzato G, Moulden M, Redman CW, Wheeler T (1993) Large fetal
heart rate decelerations at term associated with changes in fetal heart rate variation. Am J
Obstet Gynecol 168:105–111
Dawes GS, Redman CW (1993) Computerised and visual assessment of the cardiotocograph. Br J
Obstet Gynaecol 100:701–702
23 Bibliography of Geoffrey S. Dawes 511

1994
Dawes GS (1994a) Fetal physiology: historical perspectives. In: Thorburn GD, Harding R (eds)
Textbook of fetal physiology. Oxford University Press, Oxford, pp 1–5
Dawes GS (1994) Obituary: Joan Mott. The Independent, 6 May 1994
Dawes GS, Serra-Serra V, Moulden M, Redman CW (1994) Dexamethasone and fetal heart rate
variation. Br J Obstet Gynaecol 101:675–679

1995
Dawes GS (1995) Beat-to-beat variation. Am J Obstet Gynecol 173:349
Dawes GS, Moulden M, Redman CW (1995) Computerized analysis of antepartum fetal heart rate.
Am J Obstet Gynecol 173:1353–1354

1996
Dawes GS (1996) Comparison of the effects of meperidine and nalbuphine on intrapartum fetal
heart rate tracings. Obstet Gynecol 87:158–159
Dawes GS, Moulden M, Redman CW (1996) Improvements in computerized fetal heart rate analy-
sis antepartum. J Perinat Med 24:25–36

1997
Magee LA, Dawes GS, Moulden M, Redman CW (1997) A randomized controlled comparison of
betamethasone with dexamethasone: effects on the antenatal fetal heart rate. Br J Obstet
Gynaecol 104:1233–1238

1998
Mandruzzato G, Meir YJ, D’Ottavio G, Conoscenti G, Dawes GS (1998) Computerised evaluation
of fetal heart rate in post-term fetuses: long term variation. Br J Obstet Gynaecol 105:
356–359

1999
Dawes NW, Dawes GS, Moulden M, Redman CW (1999) Fetal heart rate patterns in term labor
vary with sex, gestational age, epidural analgesia, and fetal weight. Am J Obstet Gynecol 180:
181–187
Name Index

A B
Abman, Steven Herbert, 104, 380, 383 Bacon, Sir Francis, 47, 48, 50, 65, 189, 478, 479
Acland, Sir Henry Wentworth, 44, 50, Ballantyne, John William, 348–350
52–54, 56 Banks, Sir Joseph, 57
Adair, Fred Lyman, 28, 85, 354 Banting, Sir Frederick Grant, 172
Adamsons, Karlis Jr., 73, 87–91, 303, 439 Barclay, Alfred Ernest, 3, 25, 26, 29, 56, 58,
Adelmann, Howard Bernhardt, 155 59, 68, 71, 149, 169, 380, 450
Adolph, Edward Frederick, 127, 129, 130, 490 Barcroft, Sir Joseph, 9, 17, 19, 22–34, 58, 59,
Adrian, First Baron Edgar Douglas, 24, 170 68–71, 86, 100, 119, 147, 187, 189,
Ahlfeld, Johann Friedrich, 83, 394, 395, 448 242, 264, 308, 309, 335, 379–381, 396,
Alexander, Duane, 494 488, 490, 494
Alexander, Pauline, 17, 191 Barker, David J.P., 207, 208, 220, 221, 454,
Alexander the Great, 113 457, 475
Allen, Edgar, 259 Barron, Donald Henry, 12, 23–26, 30, 31, 33,
Allen, Willard Myron, 259 47, 58, 151, 242, 285, 297, 308, 309,
Althoff, Friedrich, 10 490, 494
Altman, Joseph, 236, 238 Barry, Martin, 117
Amoroso, Emmanuel Ciprian, 71, 143, 438 Bassett, John, 293, 296, 445, 449, 454
Anderson, Anne, 445 Bathurst, George, 43
Andrew, James, 52, 55 Battaglia, Frederick Camillo, 152, 196, 197,
Anselmino, Karl-Julius, 16 302, 380, 382
Apgar, Virginia, 79, 81, 89–91, 334, 335, Bayes, Thomas, 483
350, 490 Bayliss, Sir William Maddock, 258
Aranzi, Giulio Cesare (Arantius), 47, 114 Beard, Richard William, 351, 380, 382
Ardran, Gordon Melville, 59, 66, 68, 70, 73, Bell, Alexander Graham, 291
100, 438, 458 Benirschke, Kurt, 113, 144, 154, 184, 333, 355
Aristotle, 113–115, 138, 387 Bennett, Laura, 448
Aschheim, Selmar, 259 Bergström, Sune Karl, 261, 262
Ashton, Norman Henry, 342 Bernard, Claude, 2, 19, 117, 191, 478, 480
Assali, Nicholas Salem, 197, 311, 312, 351, Bert, Paul, 11
352, 384, 464, 467 Best, Charles Herbert, 172
Assheton, Richard, 125, 142, 187 Bezos, Jeff, 481
Austin, Colin Russell, 367 Billingham, Rupert Everett, 307
Avery, Mary Ellen, 282, 286–288, 293, 295, Binns, Wayne, 268
336, 353, 354, 381 Bird, Forrest M., 338
Avery, Oswald Theodore, 125 Bird, John, 57

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 513
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5, © American Physiological Society 2013
514 Name Index

Blair-Bell, William, 332, 349, 472 Churchill, Winston Leonard Spencer, 2

Blood, Arlin Brice, 246, 330, 347 Clarke, Sir Cyril Astley, 304
Bocking, Alan D., 198, 380, 383, 384, 400 Clarke, Sir George, 65
Boddy, Kenneth, 397, 440, 473 Clements, John Allen, 106, 282, 284–286,
Bohr, Christian, 301 288, 289, 490, 494
Bonnar, John, 445 Cleopatra VI, 114
Bourgeois, Louise, 387 Clifford, Stewart Hilton, 85, 333
Bourne, Gordon, 144 Cockburn, Forrester, 183, 198, 439
Boyd, James Dixon, 33, 139, 140, 142, 144 Coghill, George Ellett, 24, 242, 243
Boyd, Richard, 145, 170, 494 Cohnstein, Isadore, 12
Boyd, Sir Robert, 145, 170, 290, 340, 494 Coiter, Volcher, 114
Boyle, Robert, 48, 83 Coleridge, Samuel Taylor, 4
Brambell, Francis W.R., 10, 19, 307 Collier, William, 51, 54, 56
Brecht, Bertolt, 481 Collingwood, Robin George, 128
Bridges, Colin Blackman, 122 Colombo, Matteo Realdo, 114, 138
Britton, Hubert G., 17 Comline, Robert, 264, 445, 454, 490
Brody, Samuel, 184, 199 Comroe, Julius Hiram Jr., 65, 71, 106, 284,
Bronk, Detlev Wulf, 64–66 288, 292, 438, 482, 484
Brooks, William Keith, 121 Cone, Thomas E. Jr., 194, 327–329,
Brosin, Henry Walker, 243 331, 340
Broughton-Pipkin, Fiona, 449, 451 Cook, James, 57
Brown, Michael Stuart, 485 Cookes, Sir Thomas, 65
Browne, Thomas, 1, 8 Corker, Charles S., 265
Brown-Grant, Keith, 266, 267 Corner, George Washington, 139, 141, 143,
Buckingham, Sue, 289, 295 145, 149, 156, 259
Budin, Pierre Constant, 194, 329, 330 Correns, Carl Franz J.E., 120
Buffon, Georges Louis Leclerc Comte, 198 Couney, Martin Arthur, 330–332
Burdon-Sanderson, Sir John, 53, 54, 56, 183 Creasy, Robert Kenwood, 299, 353, 437
Burn, Joshua Harold, 64, 261 Crick, Francis Harry Compton, 125, 126
Bush, Vannevar, 147, 148, 171, 174, 175 Croone, William, 115
Butenandt, Frederick Johann, 259 Cross, Kenneth William, 71, 72, 80, 84–86,
Buzzard, Sir Edwards Farquhar, 55–58 91, 192, 292, 293, 425, 438, 439, 490
Bynum, William F., 54 Crosse, Victoria Mary, 331, 332, 342
Cushing, Harvey Williams, 55, 58, 258, 266

C
Cadogan, William, 328, 329 D
Cairns, Sir Hugh William Bell, 57, 58, 440 da Capri, Giacomo Berengario, 114
Calder, Andrew, 445 da Vinci, Leonardo, 166
Caldeyro-Barcia, Roberto, 150, 399, 403, Dale, Sir Henry Hallett, 170, 258
404, 490 Dancis, Joseph, 147, 195, 196, 342, 385
Campbell, Kate Isabel, 341, 342 Darwin, Charles, 146, 309
Cannon, Walter Bradford, 2, 191, 347 Darwin, Erasmus, 146
Carpenter, William Benjamin, 139 Dawes, Geoffrey Sharman, 5, 6, 19, 26, 59,
Carson, Rachel, 489 63–75, 81, 83, 85–88, 90, 91, 97–107,
Cassin, Sidney, 70, 87, 97–105, 309, 439, 192, 199, 257, 261–263, 265, 267, 293,
449, 490 295, 298, 299, 309, 370, 379, 380,
Catz, Charlotte, 494 391–402, 404–407, 421–430, 433–460,
Challis, John Richard George, 153, 263, 264, 470–475, 487, 488, 490, 491, 494, 495,
269, 270, 400, 401, 433, 437, 444, 449, 499–514
488, 494 Dawes, Josiah Belton, 63
Charleton, Walter, 48 Dawes, Margaret Joan Monk, 63, 99, 106,
Chaudhuri, Gautam, 262, 313 406, 440, 449, 456, 460
Child, Charles Manning, 128, 130 Dawes, Martin Geoffrey, 63, 64
Name Index 515

Dawes, Nicholas William, 63, 75, 401, Farre, Arthur, 139

407, 459 Feldman, Jack L., 474, 475
Dawes, Reverend Josiah William, 63 Feldman, William Moses, 379, 380
Maunsell, Caroline Harriet, 63 Ferreira, Sergio, 261, 262
Williams, Alison Jennifer, 63 Finn, Ronald, 304
Dawkins, Michael, 72, 74, 293, 347, 439 First, Lewis R., 288
Day, Richard Lawrence, 346 Fisher, Sir Ronald Aylmer, 169, 306
de Graaf, Regner, 115 Fishman, Albert P., 439, 443
de Vries, Hugo Marie, 9 Fletcher, Sir Walter Morley, 55, 168
DeLee, Joseph Bolivar, 329, 349, 395 Flexner, Abraham, 54, 55
Delivoria-Papadopoulos, Maria, 290, 292, 301 Flexner, Louis Barkhouse, 23, 141, 147, 148,
Democritus, 490 384, 385, 490
Desmond, Murdina MacFarquhar, 328, 339 Flint, Tony, 445
Devoe, Lawrence Daniel, 409, 410 Florey, Baron Howard Walter, 172
Diamond, Louis K., 301–304, 350 Foex, Pierre, 457
Diczfalusy, Egon, 152, 260 Fogarty, John Edward, 176, 178
Dobbing, John, 148, 236, 237, 239 Folsom, Marion Bayard, 177
Dohrn, Anton, 119, 472 Ford, Gerald Rudolph (President), 266
Doisy, Edward Adelbert, 259 Forster, Robert Elder, 491
Doll, Sir Richard Shaboe, 169 Foster, Michael, 21, 167
Dripps, Robert Dunning, 484 Fowden, Abigail, 153, 183, 198, 264
Driscoll, Shirley, 154, 333, 355 Fowler, Kemp, 293
Ducsay, Charles Andrew, 270, 271 Fox, Harold Edward, 154, 355, 391–393, 440
Duff, Raymond Stanley, 372, 373 Fox, William Willis, 224, 380, 383
Dumas, Jean Baptiste Andre, 117 Franklin, Kenneth James, 22, 25, 26, 28, 29,
Dunham, Edward Kellogg, 22 33, 34, 56–59, 488
Dunn, Peter MacNaughton, 196, 328, 334, Freda, Vincent J., 303, 304, 350
338–340, 350, 387 Fremont-Smith, Frank, 384–386
Freud, Sigmund, 310

E
Eastman, Nicholson Joseph, 15–21, 67, 79, G
83–85, 151, 350, 490 Galen (Claudius Galenus), 3, 26, 27, 138, 309
Eliot, Thomas Stearns, 487 Galton, Sir Francis, 146, 169
Elvidge, Harry, 445, 450 Garrod, Sir Archibald Edward, 54
Embry, Mostin, 445 Gennser, Gerhard Bo, 448, 473
Emerson, Ralph Waldo, 388 Gesell, Arnold Lucius, 332
Enders, Allen Coffin, 143 Gevers, Rudolf Hans, 380–382
Ent, Sir George, 44 Giffard, Sir John, 64
Eskes, Tom Kees Anton Bonifacius, 116, 473 Gilbert, Raymond Dwight, 86, 102, 103,
Evelyn, John, 50 311, 312
Exley, Donald, 265 Gilford, Hastings, 187
Giussani, Dino Antonio, 437, 471
Gluck, Louis, 289, 290, 335
F Goldstein, Joseph Leonard, 485
Faber, Jan Job, 146, 148, 149, 152, 384 Goodenough, Sir William Macnamara, 56
Fabrizio, Girolamo (Fabricius de Goodlin, Robert Clair, 395, 402, 404, 405, 409
Aquapendente), 117 Goodman, Jonathan, 441, 443, 448
Fairbairn, John, 9, 10 Gordon, Harry H., 197
Falk, Gertrude, 191 Gorman, John G., 304, 350
Falkner, Frank Tardrew, 154, 197, 198 Gowers, William Richard, 81, 82
Falloppio, Gabriele, 114 Greenfield, Archibald David Mant, 17, 241
Faraday, Michael, 21 Gregg, Alan, 177
Farquharson, Ray Fletcher, 172 Gregory, George Albert, 292
516 Name Index

Gregory, Harry, 267 Hill, Joseph Lister, 177, 178

Gropius, Walter, 4 Hill, Sir Austin Bradford, 169
Grosser, Otto, 143, 148 Hinshelwood, Cyril Normal, 1, 50, 477
Grover, Robert F., 102 Hippocrates, 114, 337, 387
Gruenwald, Peter, 145, 195, 197, 199, 285, His, Wilhelm, 124
286, 355 Hoffmann, Friedrich Albin, 16
Grulee, Clifford Grosselle, 332, 333 Holm, Louis W., 268, 269, 293
Guillemin, Roger Charles Louis, 266, 267 Holmes, Oliver Wendell, 4, 327, 381
Gunn, James Andrew, 55, 58, 59 Holt, Luther Emmett Jr., 195, 349
Gurdon, Sir John Bertrand, 130 Homer, 433
Hon, Edward Harry Gee, 352, 399, 402
Hooke, Robert, 48
H Hooker, Davenport, 396
Haeckel, Ernst Heinrich Philipp August, 118 Hoover, Herbert Clark (President), 174
Hafez, Elsayed Saad Eldin, 145, 380, 382 Hopkins, Sir Frederick Gowland, 170, 189
Haldane, John Burdon Sanderson, 183 Hoppe-Seyler, Ernst Felix Immanuel, 11
Haldane, John Scott, 21, 54 Hornsby, Thomas, 57
Haldane, Lord Richard Burdon Sanderson, Horvath, Tamas, 468
54, 168 Howie, Ross Nesbitt, 294, 295, 457
Hallman, Mikko, 290 Hubel, David Hunter, 239, 240, 425
Halson-Brown, Sue, 406 Hubrecht, Ambrosius Arnold Willem, 140
Hamilton, William James, 113, 139, 140, 144 Huch, Albert, 345
Hammond, Sir John, 185, 187, 188, 259, 423 Huch, Renate, 345
Hanson, Marc, 448 Huehns, Ernst Reinhard, 300
Hanson, Mark Adrian, 220, 221, 380, 383, Huggett, Arthur St. George Joseph McCarthy,
437, 441, 451, 471, 472 9–11, 15–21, 23, 24, 27, 31, 32, 34
Harding, Richard, 198, 380, 383, 384, 437, Hugh-Jones, Philip, 422, 423
449, 450, 455, 457, 475, 494 Hull, Sir David, 72, 347
Harris, Geoffrey Wingfield, 263–267 Hunter, Jehu, 494
Harrison, Ross Granville, 116, 121, 128 Hunter, John, 149
Hartsoeker, Nicolas, 115, 116 Hunter, William, 116, 149
Harvey, William, 3, 11, 27, 28, 43–48, 58, Hutchison, Sir Robert, 47, 387
115, 262, 266, 270, 309, 457, 478 Huxley, Thomas Henry, 5, 50, 142, 170
Haselhorst, Gustav, 16 Hwang, Joseph, 494
Havard, Robert Emlyn, 64
Hawksmoor, Nicholas, 65
Heap, Robert Brian, 269, 445 I
Hebb, Donald Olding, 238 Irving, Frederick Carpenter, 380, 381
Hector, Sir James, 299
Heisenberg, Werner, 147, 308
Hellegers, André, 151, 368, 369 J
Hellman, Louis M., 148, 385 Jackson, Edith Banfield, 332
Hendricks, Charles Henning, 469 Jacobi, Abraham, 349
Herrick, Charles Judson, 239, 243 Jacobson, Marcus, 240
Herrick, Clarence Luther, 243 James, Leonard Stanley, 81, 89, 90, 99, 334,
Herrmann, Walter L., 465, 466 350, 439, 443
Hertig, Arthur Tremain, 145 Janský, Jan, 301
Hertwig, Wilhelm August Oscar, 117, 119 Jeffress, Lloyd Alexander, 239, 243, 244, 384
Hess, Julius Hayes, 331 Jensen, Arne, 89, 427, 437, 441, 455
Heymann, Michael A., 100, 104, 286, 310, Jerome, William John Smith, 54
445, 455 Johannsen, Wilhelm Ludvig, 122
Highmore, Nathaniel, 48, 115 Johnson, Eldridge Reeves, 65
Hilbert, David, 482 Johnston, Barbara M., 441, 443, 449, 450, 454
Hill, Archibald Vivian, 301 Johnston, Paul, 454
Name Index 517

Jones, Colin T., 380, 384, 423, 426, 445, Levine, Philip, 301
449, 454 Levine, Samuel Zachary, 197
Jost, Alfred, 260 Lewis, Clive Staples, 64
Jost, Gilbert, 393 Lewis, Michael, 245
Lewis, Sir Thomas, 170, 171, 180, 486
Liggins, Sir Graham Collingwood “Mont”,
K 106, 263, 268, 269, 271, 284, 294–299,
Keibel, Franz Karl Julius, 124 391, 393, 394, 398, 407, 427, 449, 451,
Keilin, David, 119 453, 457, 458, 494
Kellogg, Howard Butters, 27 Liley, Sir Albert William, 268, 302–304
Kennedy, Evory, 402 Linacre, Thomas, 48, 53
Kennedy, John Fitzgerald (President), 177, 178 Linton, Elizabeth Anne, 471
Kennedy, Thomas J. Jr., 177 Lion, Alexandre, 330
Kennedy, Peter Carleton, 268 Little, Arthur Dehon, 66
Kepler, Johannes, 57 Little, William John, 79–82
Kerr, John Martin Munro, 349 Lobo, Rogerio Arnaldo, 467, 468
King Charles I, 43, 45 Longo, Lawrence Daniel,
King Charles II, 50 Lower, Richard, 49
King Henry VIII, 50, 64 Lübbers, Dietrich Werner, 344
King James I, 43 Lubchenco, Lula, 195, 196
King James II, 56 Lucey, Jerold Francis, 306, 369, 373, 374
King Richard III, 82 Ludwig, Carl, 26, 124
King William III, 56 Lumbers, Eugenie Ruth, 437, 443, 449
Kinyoun, Joseph James, 173
Kitterman, Joe, 445
Kleiber, Max, 199 M
Knecht, Michael, 494 Mackenzie, Colin, 149
Koch, Sigmund, 244 Macklem, Peter T., 483
Koestler, Arthur, 3, 4 Macklin, Charles Clifford, 283, 288
Koos, Brian John, 397, 398, 437, 441, 447, 474 Macy, Josiah Jr., 19, 384–386
Körber, Ernst, 301 Mall, Franklin Paine, 124
Krayer, Otto, 64, 65 Malpas, Percy, 267
Krebs, Sir Hans Adolph, 170, 482 Malpighi, Marcello, 47, 115
Kretchmer, Norman, 486, 494 Mandelbrot, Benoît, 478
Krogh, August, 22, 199 Manning, Frank Arthur, 404
Kuhn, Thomas Samuel, 479 Marrian, Guy Frederick, 259
Marsal, Karel, 473
Marshall, Francis Hugh Adam, 258–260, 264
L Masefield, John Edward, 4
Ladd, Kate Macy, 384 Masur, Jack, 175
Laennec, René Theophile, 402 Matthews, Bryan Harold Adrian Cabot, 24
Lamarck, Jean-Baptiste, 117 Mayow, John, 49
Landsteiner, Karl, 301 McCance, Robert Alexander, 19, 29, 188–194,
Langhans, Theodor, 140, 141 293, 367, 422
Lankester, Edwin Ray, 53 McCleary, George Frederick, 330
Lantos, John D., 373 McClure, Michael, 494
Lasker, Albert Davis, 176, 178, 304 McCulloch, Warren Sturgis, 244
Lasker, Mary, 178 McDonald, Thomas Joseph, 271
Lathrop, Julia Clifford, 349 McKenzie, Ian, 445
Lawrence, Robert Daniel, 189, 410 Mead, Jeremiah (Jere), 282, 286–288
Lee, Matthew, 1, 52, 264 Medawar, Sir Peter Brian, 479, 480
Legner, Wolfram Karl, 243 Mellanby, Sir Edward, 168, 191
Lelong, Marcel, 84 Mellanby, Sir John, 9, 10
Les Chermignonards Désenchantés, 343 Mellor, David James, 19, 23, 34, 297, 298
518 Name Index

Mendel, Gregor Johann, 120 Parer, Julian Thomas “Bill”, 407, 448
Mentor, 433–460 Parkes, Sir Alan Sterling, 259
Merritt, Thurman Allen, 290 Parmelee, Arthur Hawley, 333
Meschia, Giacomo, 33, 302, 311, 308, 382 Parran, Thomas, 174
Minot, Charles Sedgwick, 123, 124, 142, 183, Parsons, Sir Leonard Gregory, 190, 191,
184, 193, 195 332, 349
Mishell, Daniel Randolph Jr., 466 Paterson, Donald, 427
Mitchell, Murray, 103, 445 Patrick, John Elgin, 399, 445, 446, 449
Moncada, Sir Salvador, 262 Pattle, Richard Eric, 281–283, 285, 286, 289
Moog, Florence, 295 Patz, Arnall, 342
Moore, Benjamin, 54 Pauling, Linus Carl, 243
More, Sir Thomas, 82, 208, 241, 408 Paulsen, C. Alvin, 265
Morgan, Thomas Hunt, 123, 122, 126 Pearson, Karl, 169
Morison, John Edgar, 355 Peel, Sir John Harold, 349, 369, 370
Morris, Sir William Richard, Lord Nuffield, Perks, Anthony Manning, 101, 309, 442
44, 57 Perutz, Max Ferdinand, 483, 484
Morton, Daniel Green, 490 Petty, Sir William, 49
Moss, Samuel, 494 Pfeiffer, Carroll Athey, 265, 266
Mossman, Harland Winfield, 113, 143, 149 Pflüger, Eduard Friedrich Wilhelm, 12, 83
Mott, Joan C., 67, 74, 86, 87, 97, 99, 100, 430, Piaget, Jean William Fritz, 239, 244
443, 445, 449, 450, 454, 458 Pickering, Sir George White, 422
Moulton, John Fletcher, 168 Pitkin, Roy Macbeth, 458
Muller, Hermann Joseph, 123, 122 Platt, John Rader, 483
Munck, Allan, 266 Pohlman, Augustus Grote, 27
Myatt, Derek, 445 Poincaré, Jules Henri, 482
Myers, Dean Allen, 270 Polanyi, Michael, 478
Polin, Richard Alan, 383
Pollack, William, 304
N Popper, Sir Karl Raimund, 479
Naeye, Richard L., 154 Potter, Edith Louise, 348, 354
Naftolin, Frederick, 263, 264, 266, 467, 468 Power, Gordon Gilbert, 347, 348, 444
Nathan, David Gordon, 369, 371 Poynter, Frederick Noël Lawrence, 51, 52
Nathanielsz, Peter, 271, 382, 426 Prechtl, Heinz Friedrich, 398
Needham, Noel Joseph Terence Montgomery, Prévost, Jean Louis, 117
127, 126, 127, 130, 242 Preyer, Thierry Wilhelm, 13, 27, 31, 243, 380
Needham, Walter, 49, 115 Prichard, Marjorie Mabel Lucy, 29, 73, 450
Nelson, Nicholas Macy, 287, 334, 338 Proust, Marcel, 294
Newman, Horatio Hackett, 184 Purves, Michael J., 396, 454
Newton, Sir Isaac, 481
Nijhuis, Jan, 448, 471
Nixon, D.A., 17 Q
Queen Anne, 56
Queen Elizabeth II, 194, 299, 452
O Queen Mary II, 56
Ockham, William of, 483 Quilligan, Edward James, 399, 393, 402, 490
Olson, David Mark, 426
Oppenheimer, Ella Hutzler, 287
Osler, Sir William, 54, 55, 59, 170, 430 R
Owens, Ella Uhler, 341 Radcliffe, John, 56, 59
Owens, William Councilman, 341 Rahn, Hermann, 293
Raju, Tonse, 494
Ramsey, Elizabeth Mapelsden, 144, 149,
P 151, 490
Paget, Sir James, 51, 170 Ransdell, Joseph Eugene (Senator), 171, 174
Pander, Heinrich Christian, 116 Rappleye, Willard Cole, 384
Name Index 519

Redman, Christopher Willard, 405, 430, 448, Shannon, James Augustine, 176–178, 465
448, 460 Shelley, Heather, 74, 443, 454
Reeves, John Thomas, 101 Sherrington, Sir Charles Scott, 54, 170
Reid, Duncan Earl, 333 Shriver, Eunice Kennedy, 179
Reitz, Julius Wayne, 308 Silver, Marion, 445
Reynolds, Samuel Robert Means, 9, 18, 68, Silverman, William, 305, 330, 332, 337, 341,
69, 149, 150, 489 343, 344, 346
Riley, Richard Lord, 293 Silverstein, Arthur Matthew, 307
Ringer, Sidney, 310 Smellie, William, 387
Ritchie, James Whiteford Knox, 445, 447, Smith, Clement Andrew, 16, 333, 334, 381,
449, 454 387, 396
Robb-Smith, Alastair Hamish Tearloch, 51 Snyder, Franklin Faust, 395
Robinson, Arthur, 142 Sobotta, Robert Heinrich Johannes, 117
Robinson, Jeffrey, 269, 295, 392–394, 396, Soemmerring, Samuel Thomas, 116
400, 445, 454, 454, 473 Spanner, Rudolf, 144
Rock, John, 145 Spemann, Hans, 123, 125, 130
Romijn, Christiaan, 16 Sperry, Roger Wolcott, 238–240
Roos, Jacob, 16 Stahlman, Mildred Thornton, 334, 335–337,
Roosevelt, Anna Eleanor, 174 372, 373, 494
Roosevelt, Franklin Delano (President), 173 Stallworthy, John Arthur, 457
Rooth, Gösta, 345 Starling, Ernest Henry, 258
Rose, Charlie, 481 Stave, Uwe, 381
Rose, James Carrington, 270 Stern, Leo, 391
Rosen, Mortimer G., 391 Stetson, Rufus E., 301
Rosenfeld, Morris, 395 Stevens, Andrew, 437, 444, 450
Roughton, Francis John Worsley, 32, 488 Stevenson, James Alexander Frank, 398, 427
Roux, Wilhelm, 116, 121 Stewart, Chester B., 171, 172
Rowe, Frederick Maurice, 17 Stillman, James, 124
Rubner, Max, 199 Strahl, Hans, 142
Rudolph, Abraham Morris, 310, 311 Strang, Leonard Birnie, 97, 99, 290, 293
Rurak, Danny, 437, 442, 445, 449 Streeter, George Linius, 145, 147
Ruskin, John, 53 Stromberger, Karl, 16
Ruys, Jan Hendrick, 381 Stumpf, Samuel Enoch, 368
Ryan, Kenneth John, 266, 269, 445 Sturtevant, Alfred Henry, 122
Ryle, John Alfred, 189 Suh, Jimin,
Sunshine, Philip, 494
Sutton, Walter Stanborough, 120
S Swammerdam, Jan, 115
Sabatier, Raphaël-Bienvenu, 26 Swyer, Paul Robert, 290, 292, 335
Sadler, William, 494 Szent-Györgyi, Albert, 494
Saling, Erich, 345, 348, 351, 403
Samuelsson, Bengt Ingemar, 261, 262
Santayana, George, 2 T
Sarton, George Alfred Leon, 2 Tanner, James Mourilyan, 197, 198
Schaffer, Alexander James, 333 Tarnier, Etienne Stephane, 329
Schally, Andrew Viktor, 266, 267 Taylor, Hugh Smith, 469
Schatz, Friedrich, 15, 154 Telemachus, 433
Scheele, Leonard Andrew, 175 Tennyson, Alfred, 336
Schmorl, Christian Georg, 305 Terry, Theodore Lasater, 334, 341
Schopenhauer, Arthur, 296 Thomas, Lewis, 170, 171, 486
Schultze, Bernhard Sigismund, 394 Thompson, Lewis Ryers, 174
Scopes, Jon, 72 Thompson, Sir D’ Arcy Wentworth, 184, 186,
Selye, Hans, 209 198, 473
Severinghaus, John Wendell, 345 Thorburn, Geoffrey Donald, 263, 299, 383, 398,
Shakespeare, William, 82 400, 437, 445, 446, 453–455, 473, 490
520 Name Index

Thornburg, Kent LuRoy, 152, 437, 457 West, Charles, 82

Tizard, Sir Peter, 72 West, John Burnard, 293
Tolkien, John Ronald Reuel, 64 White, Theodore Harold, 422
Turnbull, Sir Alexander Cuthbert, 445 Whitman, Charles Otis, 119
Turner, Sir William, 139, 141 Whitteridge, David, 66, 73
Twain, Mark, 454 Widdas, Wilfred Faraday, 21, 490
Widdicombe, John Guy, 66, 67, 73, 439,
440, 494
U Widdowson, Elsie May, 29, 188–194, 293
Usher, Robert, 90, 291, 329, 338 Wiesel, Torsten Nils, 239, 240, 425
Wilkins, Maurice Hugh Frederick, 126
Williams, John Whitridge, 348, 349, 350
V Willis, Thomas, 48, 49
van der Spieghel, Adrian, 114 Wilson, Edmund Beecher, 120, 122
van Leeuwenhoek, Antonj, 115 Wilson, Luke Ingalls, 174
Vane, Sir John Robert, 73, 74, 100, 258, Windle, William Frederick, 24, 85–88, 90, 91,
261, 262 379, 380, 396, 490, 494
Vesalius, Andreas, 114 Wintour, Elvie Marelyn, 270
Vierordt, Hermann, 117 Wislocki, George Bernays, 145
Villee, Claude Alvin Jr., 333 Witts, Leslie John, 58, 63
Visser, Gerard Hille Adriaan, 437, 447 Wolff, Caspar Friedrich, 27, 115
von Baer, Carl Ernst, 45, 116 Wolstenholme, Sir Gordon, 422
von Bismarck, Otto Eduard Leopold, 10 Wood, Charles Evans, 437
von Euler, Ulf Svante Hansson, 260 Wren, Sir Christopher, 49
von Haller, Albrecht, 115 Wyatt, Derek G., 66, 73, 74, 391, 393, 450
von Humbolt, Friedrich Willem Christian Karl Wyatt, James, 56
Ferdinand, 10 Wyngaarden, James Barnes, 484, 485
von Kölliker, Rudolph Albert, 117 Wynn, Ralph M., 385
von Linné, Carl (Linnaeus), 57
von Neergaard, Kurt, 283, 284
von Neumann, John, 243 Y
von Reuss, August Ritter, 332 Yaffe, Sumner, 494
von Ruehl, Johann Georg, 329 Yalow, Rosalyn Sussman, 266
von Seysenegg, Erich Tschermak, 120 Yerushalmy, Jacob, 196
Young, Maureen, 28, 29, 494
Young, Winifred Ferguson, 190
W Yuan, Stanley, 102
Waddington, Conrad Hal, 208–210 Yule, Charles John Francis, 53
Walker, David, 445, 449, 452, 494 Yule, George Udny, 169
Walton, Arthur, 187
Walton, Izaak, 299, 495
Warburg, Otto Heinrich, 97, 99, 119 Z
Waterman, Alan Tower, 175 Zhang, Lubo, 221
Watson, James Dewey, 125 Zondek, Bernhard, 259
Webster, John Clarence, 142 Zuckerman, Sir Solly, 266
Weismann, Friedrich Leopold August, 117, 121 Zuntz, Nathan, 12, 15, 32, 83
Weiss, Paul Alfred, 128, 130, 243, 244 Zweifel, Paulus (Paul), 11, 15, 47, 83, 308
Subject Index

A American Pediatric Society, 332

Abortion, therapeutic, 370, 371, 374 John Howland Medal, 287, 288
Acetylcholine, 70, 74, 101, 105 American School of Psychology, 243
Acidosis, fetal, 351, 403, 406, 409 American Society of Naturalists, 142
ACOG. See American College of Obstetricians Amniocentesis, 303, 349, 351
and Gynecologists (ACOG) Amnion, 13, 138, 139, 142, 442
ACTH. See Adrenocorticotropic hormone amniotic fluid, 8, 21, 47, 146, 269, 289,
(ACTH) 290, 303, 304, 313, 351–353, 371,
Addenbrooke Hospital, Cambridge, 189–190 395, 403, 404, 444, 473
Adenohypophysis, 258, 266 Anencephaly, 217, 267
Adenosine, 400, 429 Anesthesia, maternal, 16, 70, 83, 84, 311, 392
Adipose tissue, brown, 72, 347 Angiotensin, 221, 429, 444, 449, 458
Adrenal gland, fetus, 152, 264, 268, 269, 312, converting enzyme (ACE), 261
423, 454 Anterior pituitary gland, 268
Adrenal steroids, 424 Anti-atelectasis factor, 285
Adrenocorticotropic hormone (ACTH), Anti-social personality disorder, 217
269–271, 299 Antivivisection movement, 54
Affective mood disorder, 218 Apgar score, 79, 90, 350, 404, 409
Albert Einstein College of Medicine, 404 Arginine vasopressin (AVP), 269, 450
Albert Lasker Clinical Medical Research Aristotelianism, 478
Award, 304 Artificial insemination, 188
Albert Ludwig University of Freiburg, 117 Artificial placenta, 192, 367, 370
Alpha1-adrenergic receptor, 246 Asphyxia
Alpha-fetoprotein, 352 fetal, 70, 79–91, 195, 382, 407
Alveolar type II cell (pneumocyte), 289 newborn, 67, 382
Amazon viper (Bothrops jararaca), 261 Association for the Study and Prevention of
American Academy of Pediatrics, 306, 430 Infant Mortality, 349
Virginia Apgar Award, 335 Association of American Medical Colleges,
American Association for the Advancement of 177, 179–180, 484
Science, 30, 66, 122, 142, 287, 291 Association of American Physicians, 484
American Association of Anatomists, 142 Atherogenic lipid profile, 214, 218
American College of Obstetricians and Atherosclerosis, 220
Gynecologists (ACOG), 408, Australia
430, 458 National Health and Medical Research
American Journal of Obstetrics and Council, 173
Gynecology, 466, 467 Royal Commission, 173

L.D. Longo, The Rise of Fetal and Neonatal Physiology: Basic Science 521
to Clinical Care, Perspectives in Physiology 1,
DOI 10.1007/978-1-4614-7921-5, © American Physiological Society 2013
522 Subject Index

Autonomic nervous system, 69, 70, 407 growth spurt, 235, 236
AVP. See Arginine vasopressin (AVP) metabolism, 236, 241, 245, 267
Axonal guidance, 238 neurogenesis, 217, 218, 235–241
paraventricular nucleus, 270, 271
plasticity, 236, 238, 248
B proliferative periventricular zone, 237
Baboon, 295, 400 sexual differentiation, 265–267
Barcroft Centenary Symposium, 425–426 sparing, 237
Barcroft saturators, 9 subventricular zone, 235, 237, 238
Baroreceptor, 405 Breast cancer, 216–218, 220
Bayesian inference, 483 Breast-feeding, 328, 330
Bayley Scale of Infant Development, 404 Breathing movements, fetal, 297, 352,
Baylor College of Medicine, Houston, 339 391–401, 425, 445, 453, 455, 470,
Behavior, 85, 86, 128, 209, 212, 220, 235, 472, 473
242–244, 262, 266, 281, 286, 334, Bristol University, 396
354, 382, 397, 399, 426, 474 British Association for the Advancement of
behaviorism, 243, 244 Science, 1, 186
Berliner Gewerbe Ausstellung [World Trade British Association of Perinatal Medicine, 340
Exposition], 332 British Design Award, 406, 430
Betamethasone, 296 British Medical Association, 54, 58
Bioethics, 151, 367–374 British Neonatal Society, 194
bioscience ethics, 369 British Nutrition Foundation, 194
Biology British Paediatric Association, 19, 340
cellular, 121, 129, 130, 294, 312, 383, James Spence Medal, 72, 293, 430
429, 464, 468, 478, 480, 485, 486, British Society for Experimental Biology, 188
491, 492 Bronchopulmonary dysplasia, 291, 344
molecular, 105, 129, 130, 171, 294, 312, Budin’s rule, 330
383, 429, 454, 468, 472, 473, 478,
480, 483–486, 491, 492
Biophysical profile, fetal, 352, 400, 404 C
Birth, timing, 23, 27, 113, 221, 236, 267–271, Calcium channels, L-type Ca2+, 105, 246
298, 425 California Institute of Technology, 238, 243
weight, 340 Caloric restriction, 212, 216
Blair-Bell Research Society, 430, 472 Cambridge University
Blood-bathed superfusion bioassay, 261 King’s College, 21, 126, 189, 423
Blood, fetal Medical Society, 189
circulation, 10, 28, 31, 33, 114, 137, Canada
146, 149 Institutes of Health Research, 173
pressure, 12, 31, 149, 151, 408 Medical Research Council, 172–173
respiratory gases (2.4; 5.1; 19.1), 34, 83, Privy Council, 172
137, 149, 151, 380, 423 Caput succedaneum, 351
scalp sampling, 352 Cardiac output, 23, 68, 72, 84, 86, 102, 146,
umbilical sampling, 352 310, 312, 382, 444
volume, 31, 153, 444 Cardiovascular
Body movements, 352, 398–400, 404, 405 control mechanisms, 445
Boston City Hospital, 370, 371 system, fetal, 29, 68–75, 219, 312,
Boston Lying-in Hospital, 84, 333, 380, 447 427, 445
Bradycardia, fetal, 70, 87, 403, 407, 408 Carnegie Institution of Washington
Bradykinin, 102, 261, 267, 429 Department of Embryology, 18, 124,
Brain 143, 147
basal ganglia, 305 Department of Terrestrial Magnetism,
brain sparing, 237 147, 148
cognitive development, 242–245 Case Western Reserve University, 469
gene expression, 209–211, 235, 241 Cat, 10, 104, 149, 193, 240, 285
Subject Index 523

Catecholamines, 70, 71, 454 Congressional Gold Medal, 178

Cayo Santiago Field Station, Puerto Rico, 86 Consultation de Nourrissons, 330
Center for Research in Child Health, 178 Contraction stress test (CST), 404
Century of Progress Exhibition, Chicago, 331 Convulsive disorders, 245
Cerebral Cook County Hospital, 331
artery and signal transduction mechanisms, Cornell University, 197, 271, 426
blood flow, 245–249 Coronary artery disease, 207, 214–216,
cortex, 85, 237, 241 218, 220
dysregulation, 245, 248, 249 Cortical ocular dominance columns, 240
hypoxia, 246 Corticosteroid therapy, 296
ischemia, 246 Corticotrophin releasing hormone (CRH),
Cerebral palsy, 80, 84, 90, 217, 218, 245, 344, 269–271
404, 410, 429 Cortisol, 220, 270, 271, 292, 294, 295,
Cervix, dilatation of, 350 298, 299
Charing Cross Hospital, London Council for International Organizations of
Sunley Research Centre, 428, 429 Medical Sciences, 240
Chemical Defence Experimental Cow
Establishment, Porton Down, 281 Guernsey, 268
Chemoreceptor, peripheral arterial, 398 Holstein-Friesian, 268
Chicago Lying-in Hospital, 331, 354 CRH. See Corticotrophin releasing hormone
Children’s Bureau of the Department (CRH)
of Labor, 349 Croonian Lecture, 30, 259
Children’s Hospital, Birmingham, 190 Cyclo-oxygenase, 103, 104, 262
Children’s Hospital, Philadelphia, 383 Cytochrome P450, 270
China, 224, 490
“Great Leap Forward”, 219
Chorion D
frondosum, 140 Dartmouth Conference on Learning
laeve, 140 Theory, 243
villosum, 140 Dawes Symposium, 423–427
Chorionic gonadotropin, 351 Death Valley in utero, 310
Chromosomal analysis, 304, 351 Decidua, 13, 139, 142, 144
Chronic catheterization, fetus, 308–310, 425 Dégation à la Recherche Scientifique et
Ciba Foundation Symposia, 421–425 Technique, 240
Circadian periodicity, 313 Developmental
Classical Association of England origins of adult health and disease, 219
and Wales, 187 plasticity, 238, 248
Clinical investigator, 352, 368, 379, 468, 469, programming, 153, 219
484, 485 Dexamethasone, 406
Coagulation factor VII, 216 Diabetes, Type 2, 214, 219, 220
Cognition, 237, 240 Dipalmitoyl phosphatidylcholine
development of, 245 (lecithin), 289
Cognitive function, 217, 218, 237 District of Columbia General Hospital,
Cold Spring Harbor Symposium, 425 Washington DC, 342
Columbia University, 89, 101, 120, 122, 304, DNA
305, 346 in blood, 353
Children’s Hospital of New York- methylation, 210, 211, 214
Presbyterian, 383 Dog, 12, 23–25, 28, 29, 49, 59, 72, 82, 103,
Commander of the Order of the British 104, 114, 116, 193, 285
Empire, 185, 188, 194, 342, Down syndrome cell adhesion molecule
430, 452 (DSCAM), 238
Companion of Honour, 194 Drosophila melanogaster, 122
Conference on Foetal Breathing, 470 Ductus arteriosus, 23, 25–27, 31, 58, 68,
Congenital malformation, 268, 426 71–74, 100, 104, 310, 312, 397
524 Subject Index

Ductus venosus, 27, 31, 68, 71, 73 Finland, 220, 290

Duke University, 244 Flowmeter
Dutch “Hunger Winter” density, 74
cardiovascular sequelae, 214–216 electromagnetic, 74, 105, 106, 312, 450
metabolic sequelae, 214, 215 Fly room, 122
neuropsychological sequelae, 217–218 Food and Drug Administration, 173, 410
other sequelae, 213, 218 Food Investigation Board, 28
Foramen ovale, 23, 26, 27, 68, 71–73
Foulerton Research Fellowship, 66
E Foundling Hospital, 328, 329
Egypt, 137 Framingham study of heart disease, 220
Electrocorticogram, fetal, 391 Fructose, 17, 18
Electrohysterography, 410 Fruit fly, 122
Electromyographic, diaphragmatic, 396, 397
Electronic fetal heart rates, 352, 402–408
Elephant, 30, 193, 199, 472 G
Embryo, 13, 18, 32, 43, 46, 47, 113–115, 117, Galilean-Harveian hypothetico-deductive
121, 126, 138, 140, 145, 146, 183, method, 477
184, 207, 224, 300, 306, 370, 423 Gallamine, 405
Embryology Gene expression, 208, 209, 221, 241
epigenesis, 45, 115, 119, 209, 210 regulation of, 210, 481
preformation, 45, 115, 116, 119 General-Adaptation-Syndrome, 209
Encephalopathy, 245, 306, 407, 409 General Council of Medical Education, 52
Endocrinology, 3, 8, 145–154, 257–271, 367, Genetics
381, 382, 400, 453, 478 diagnosis, 353
reproductive, 257–260, 469 imprinting, 153
Environment, 2, 6, 23, 31, 85, 107, 126, 177, Genome
184, 187, 190, 199, 209–211, 219, organization, 481
247, 287, 346, 347, 354, 373, 383, regulation, 223, 241, 248, 249, 464,
427, 443, 444, 446, 487, 488, 481, 492
490, 492 Genomics, 105, 153, 154, 156, 209–211, 235,
Epigenetics, 122, 153, 183, 207–224, 241, 245 480, 481, 492, 493
Epilepsy, 217 Genotype, 122, 210, 211, 221
Erythroblastosis fetalis, 268, 301 Georgetown University, 151
Estrogen, 259, 260, 265–267, 269, 425 Joseph and Rose Kennedy Institute for the
European Society of Cardiology, 407 Study of Human Reproduction and
Exchange transfusion, fetus, 303, 304, 306 Bioethics, 368
Experimentation, human, 261, 345, 369, 370 Germany, 11, 51, 53, 72, 123, 125, 191–193,
346, 455
Wuppertal, 191
F Gestation, 7, 81, 101, 142, 179, 188, 212, 235,
Farquharson Commission, 172 268, 292, 327, 370, 381, 393, 423,
Federation of American Societies for 451, 470
Experimental Biology, 184 Glucocorticoid, 263, 271, 288, 294–296, 298
Fels Research Institute, 197 therapy, antenatal, 298, 299, 427
Fertilization, 7, 113, 117, 119, 120, 353, 482 Glucose, 17–20, 87–89, 91, 214, 215, 218,
Fetal alcohol syndrome, 221 220–222, 291, 338, 400, 426
Fetal and Neonatal Physiological Society, 427, Glycogen, 10, 17, 87, 117
463–475 GnRH. See Gonadotrophin releasing hormone
Fetal Origins of Adult Health and Disease, (GnRH)
207–224 Goat, 9, 10, 13, 17, 19, 23–25, 30, 100,
Fetal oxygenation, 23, 33, 79, 84, 151 102–104, 138, 193, 424
oxygen consumption, 71, 100, 400, 423 Gonadotrophin releasing hormone (GnRH),
Fetal viability, 70, 370, 372 264–266
Subject Index 525

Gordon Research Conferences, 387 Hemorrhage, intracerebral, 245

Goutte de Lait, 330 Hering-Breuer respiratory reflexes, 87
Governmental support, 31, 167–180 High altitude, 12, 21, 33, 102, 151, 196, 271
Gradient theory, 128 Hippocampus, 235, 238, 271
Growth, fetal, neonate Hippopotamus, 30, 193
rates, 107, 186, 188, 220, 424 Histamine, 105, 429
restriction, 8, 79, 195, 198, 221, 237, 300, Histone modifications, 211
312, 327, 353 Hixon Symposium, 243, 384
Growth Spurt, 235, 236 Holland, 16, 194, 212, 473
Guinea pig, 12, 18, 74, 85–87, 149, 183, 184, Homeostasis, fetal, 19, 264, 313, 385–387,
193, 194, 236, 261, 391, 393, 423, 438
400, 492 Homunculus, 115
Gynecologic Investigation, Gynecologia, Hôpital de la Charité, 331
463–475 Hormone, posterior pituitary, 191, 258
gonadotrophin, 264
Horse, 187, 193, 264
H Hospital for Sick Children, University of
Haldane-Barcroft blood gas manometer, 119 Toronto, 292
“Haldane Commission”, 54 Howard Florey Institute, University of
“Haldane Principle”, 168 Melbourne, 270
Hamilton Island, Queensland, 383 Human, 1, 7, 45, 71, 82, 103, 113, 137, 167,
Hammersmith Hospital, London, 171 183, 207, 235, 260, 283, 332, 367,
Postgraduate Medical School, 171, 293 383, 395, 423, 443, 472, 483
Harvard University, 16, 22, 269 Hutchinson-Gilford progeria syndrome, 187
Medical School, 4, 65, 124, 145, 154, 239, Hyaline membrane disease, 179, 286, 287, 294
371, 380, 385, 423 Hydrocephalus, 268
Harvey’s question, 47 Hyperbilirubinemia, 305–306
Healthcare, regionalization, 338, 339 Hypercapnia, 79, 246, 395, 397
Health Research Facilities Construction Act Hyperemesis gravidarum, 224
(1956), 177 Hyperkalemia, 91, 291
Heart, fetal Hyperoxia, 341–344, 346, 486
cardiac carbohydrate, 87 Hypertension, 103, 105, 178, 207, 215, 216,
cardiac output, 312, 382, 444 218, 219, 221, 222, 261, 457, 484
Heart rate, fetal Hypocapnia, fetal, 395
beat-to-beat variability, 395 Hypoglycemia, 291, 306, 340, 382
deceleration Hypophyseal-pituitary portal circulation, 265
early; “type I” dips, 403 Hypophysectomy, 264, 267
late; “type II” dips, 403 Hypothalamic-pituitary, 214, 270
variable, 403 adrenal axis, 268–271, 297, 298, 400,
monitoring, 350–352, 402–409, 448, 454, 455 424, 427
ST-waveform analysis, 409 ovarian axis, 217
variability, 67, 395, 400, 405–409, Hypothesis
448, 471 aromatization, 267
Hebrew scripture, 138 hyper-relaxation, 247, 248
Hector Medal, 299 hypo-contractile, 247, 248
Hedgehog, 457 multiple working, 483
Hematology, 300–304, 350 thrifty genotype, 221
Hemoglobin, 16, 17, 21, 23, 33, 104, 150, 300, thrifty phenotype, 221
301, 345 Hypoxia, 22, 74, 79, 83, 86, 97, 101, 104,
oxyhemoglobin saturation, 9, 11, 12, 16, 105, 107, 146, 211, 221, 236, 246,
23, 31, 71, 72, 87, 151, 301 248, 271, 297, 306, 310, 312, 344,
Hemoglobinopathies 346, 382, 395, 397–399, 401,
Rh disease, 303 403–407, 409, 422, 424, 446, 455,
sickle cell disease, 371 470, 472, 485
526 Subject Index

I Königliche Landwirtschaftliche Hochschule,

Immunoglobulins (IgG), 197, 307 Berlin, 12
Immunology, 257, 306–308, 427, 478
Incubator, newborn, 329
Indiana University, 27 L
Infant Labor
premature, 195, 286, 287, 292, 294, 305, course of, 346, 350, 351, 404
310, 328–333, 335, 340–344, 346, initiation, 153, 269–271
347, 367, 379, 403, 486 premature, 15, 104, 154, 268, 271, 292,
Infant’s Hospital, London, 379 296, 298, 382, 427
“Inklings”, 64 Laboratory of Hygiene in Marine
Insulin-like growth factor I, II, 214, 216, 263 Hospital, 174
Intellectual development, 245 Lamarckian, 117
Intensive Care, neonatal, 8, 327–340, 372, 373 Langmuir–Wilhelmy balance, 285
International Bureau of Education, 244 Lasker Foundation, Albert and Mary Lasker
International Centre for Genetic Awards, 178
Epistemology, 244 Learning disabilities, 245
International Conference on Foetal Breathing, Leningrad siege study, 222
470, 473 LH. See Luteinizing hormone (LH)
International Congress in Paris, 482 L’Hôpital Maternité, 329
International Union of Physiological Life Course epidemiology, 223
Sciences, 426 Liggins Institute, 299, 393
Intrauterine growth restriction (IUGR), 8, 79, Logical positivism, 244
153, 195, 197, 221, 237 Loma Linda University, 221, 270, 312, 347,
Intrauterine myometrial pressure, 150, 403 444, 475
In vitro fertilization, 353 Los Angeles County General Hospital, 403
IUGR. See Intrauterine growth restriction L/S ratio, 289
(IUGR) Lucey Lights, 306
Lula Gram, 196
Lung
J development, 398, 423
John Radcliffe Hospital, 56, 59, 444, 450, 454 elasticity, 283, 284
Johns Hopkins University School fetal, 12, 70, 100–104, 294–297, 299,
of Medicine, 124 312, 457
Johnson Foundation for Medical Physics, 65 lymph flow, 293
Josiah Macy Jr. Foundation, 384–385 maturation, 271, 281, 294–298, 427
conferences on Gestation, 19, 384–385 physiology, 328
Journal of Clinical Investigation, 466, 467 Luteinizing hormone (LH), 264, 265, 267
Journal of the Society for Gynecologic Lymphocytes, 307
Investigation, 467
Jupiter [Jove], Roman god, 45
M
Malnutrition during pregnancy, 223–224
K Mandelbrot set, 478
Karolinska Institute, 260 Marburg University, 344, 381
Kennedy Institute (Joseph and Rose Margaret Hague Maternity Hospital, Jersey
Kennedy Institute for the Study of City, 285
Human Reproduction Marine Biological Laboratory
and Bioethics, 368 (Woods Hole), 119
Kernicterus, 303, 305–306, 340 Massachusetts Institute of Technology,
Keystone Conferences, 387 238, 244
Kidney, 145–147, 190, 191, 383 Massey University, 19, 297
Kinderbrotonstalt, 330 Maternal and Child Health, 178, 347, 349, 490
Kleiber’s Law, 199 Maternal–fetal medicine, 347–354
Subject Index 527

Maternal–fetal medicine network, 410 Mt. Everest in utero, 83–85, 151, 310
Maternal-placental-fetal unit, 8, 137, 152, 260 Mt. Sinai Hospital, Baltimore, 285, 447
Mathilda and Terence Kennedy Institute of Museum für Naturkunde der Humboldt-
Rheumatology Trust, 429 Universität, Berlin, 141
McGill University, 90, 172, 209, 238, 291 Myelin, 194, 217, 235, 236
Medical College of Georgia, 410
Medical Research Council
of Australia, 172–173 N
of Canada, 172–173 National Academy of Sciences (NAS), 65,
of Great Britain 120–122, 142, 177, 243, 244, 262,
Dunn Nutrition Laboratory, 193 285, 287, 487
Laboratory of Molecular Biology, National Foundation–March of Dimes, 338
171, 483 Committee on Perinatal Health, 338
Medical Research Committee, National Health Service, United Kingdom,
167, 168 56, 171
of Sweden, 260 National Institutes of Health (NIH)
Melatonin, 313 Child Health and Human Development
Mendelian inheritance, 120, 122 (NICHD), 178, 335, 408, 410, 465,
Menopause, 264 486, 494
Metabolism child health day address, 335
bilirubin, 305 Clinical Center, 175
metabolic rate, 31, 72, 128, 199–200, 236, Consensus Conference, 296
344, 346 Eunice Kennedy Shriver National institute
metabolic syndrome, 207 of, 179
metabolomics, 480 Maternal–Fetal Medicine Unit
utero-placental-fetal, 312 network, 410
Michael Reese Hospital, 331 National Cancer Institute, 174
Michael Smith Foundation for Health National Center for Research
Research, Vancouver, BC, 264, 444 Resources, 374
microRNA, 210, 481 National Heart, Lung, and Blood
Microspheres, radioactive, 151, 310, 455 Institute, 175
Milani Comparetti test, 404 National Institute of Arthritis and
Mitochondria, 347 Musculoskeletal, 175
Mitochondrial uncoupling protein, 347 National Institute of General Medical
Monash University, 198, 263, 383, 452, Sciences, 178
455, 475 National Institutes of Neurologic Disease
Monica AN 24, 410 and Blindness, 342
Monkey, Rhesus, 18, 80, 86, 88, 99, 145, 149, National Library of Medicine, 90, 178, 179
150, 374, 400, 404 Research Career Developmental
anti-Rh gama-globulin (RhoGAM), Awards, 177
303, 305 and skin diseases (metabolic diseases), 175
Montevideo Unit, 404 National Medal of Science, 177, 243, 266,
Montreal Children’s Hospital, 291 287, 371
Morphogenesis, 125, 184 National Science Foundation (NSF), 175
Mortality National Society for the Prevention of
infant, 213, 220, 222, 330, 349, 354, 409 Blindness
perinatal, 404, 475 National Women’s Hospital,
Mouse, 17, 117, 153, 193, 199, 241, 268, 289, Auckland, 294
295, 307 Nature versus Nurture, 245
Movements, fetal Neonatal Society of the United
body, 398, 399, 405 Kingdom, 459
breathing, 297, 352, 391–400, 425, 445, Neonatology, 3, 8, 89, 90, 173, 288, 305,
453, 455, 470, 472, 473 328, 333, 338–340, 373, 383, 426,
rapid eye, 8, 393, 397, 470 469, 506
528 Subject Index

Nervous system, 10, 24, 31, 49, 55, 59, 69, 70, O
81, 85, 88, 101, 128, 198, 199, 217, Obesity, 218–220, 475
235–249, 260, 268, 291, 379, 381, Obstetrical Society of London, 79, 82
400, 407, 423–425, 507 Occam’s Razor, 483
Neural network theory, 244 OCT. See Oxytocin challenge test (OCT)
Neural tube defects, 217, 352 Oeuvre Maternalle des Couveuses
Neuroendocrinology, 264–268 D’enfants, 330
Neurogenesis, 217, 218, 235–241 Oligohydramnios, 354
Neurological Ontogeny, 2, 7, 118, 120, 129, 307, 397,
development, 197 423, 425
diseases, 86, 175, 245, 287 Ophthalmology, Institute of, London, 342
sequelae, 85, 246, 249, 292, 408 Oregon Health Sciences University, 148,
Neuropathology, 88, 306 152, 457
Neurophysiology, 24, 65, 398 “Organizer”, 125, 242, 297, 469
Neutrition, 17, 28, 32, 107, 138, 140, 146, Ortho Research Foundation, 304
168, 169, 184, 187, 189, 191–194, Osler Memorial Medal, 430
197, 198, 207, 210, 212–214, Ovum, fertilized, 120
217–224, 237, 239, 247, 257, 333, Ox, 193
338, 340, 367, 379 Oxford, 1, 5, 25, 43–59, 63, 64, 66, 68, 72, 75,
Newt, 125, 243 97, 98, 100, 115, 130, 192, 261,
New York Academy of Sciences, 266, 267, 309, 347, 392, 394, 397,
385–387 401, 426, 429, 430, 437, 439, 440,
Conferences on Fetal Homeostasis, 442–449, 452–455, 457, 470–473,
385–387 475, 477, 492, 502, 511
New York University, 24, 179, 195, 264, Oxford Nutrition Survey, 222
342, 486 Oxford Sonicade Ltd., 406
Bellevue Medical Center, 342 Oxford University
New York World Fair, 331 Christ Church College, 52
Nicotine, 221 Green College, 59
Nigeria, famine, 219, 224 Magdalen College, 64
Nitric oxide, 70, 104, 105, 246, 262, 270 Merton College
Nobel Laureate, 21, 130, 170, 243, 301, 477, New College, 63
479, 485, 494 St. Catherine’s College, 426
Nobel Prize in Physiology Trinity College, 43
or Medicine, 119, 122, 126, 238, University Medical School, 245
240, 262 Wolfson College, 443, 446
“No Name Society”, 387, 469 Worcester College, 64
Nonstress test (NST), 400, 404 Oximetry, fetal pulse, 408
North American Society of Pacing Oxygenation, fetal, 17, 19, 23, 33, 71, 79,
Electrophysiology, 407 84, 151
Northwestern University, 27 Oxygen consumption, 21, 31, 71, 85, 100,
Northwick Park Institute for Clinical 119, 128, 129, 308, 400, 422, 423,
Research, 171 501–504
Norway, 220 metabolism, 21, 119, 129
Nucleosome, 210, 211 Oxyhemoglobin saturation, 9, 11, 12, 16, 23,
Nuffield 32, 69–72, 87, 151, 301, 345
Foundation, 59 Oxytocin challenge test (OCT), 352, 404
Institute for Medical Research, 43–59, 66,
444, 447, 448, 472
Nutrition P
antenatal nutritional deprivation, 219 Paediatric Research Society, 335, 469, 486
total parental, 333 Parturition, initiation, 267–270, 297,
Nutrition Society, 28 423, 427
Subject Index 529

Pathology, fetus and newborn, 350, 258–260, 267–269, 271, 327, 330,
354–355, 382 338, 347–350, 352, 371, 379, 381,
Pavillion des Enfants Debiles, 329 382, 400, 402, 408, 423, 444, 463,
Pediatric Research, 469 465, 469, 471, 472, 509
Pediatric Research Society, John Howland Premature birth, 198, 281, 429
Award, 335 Prenatal care, 198, 349, 350
Pediatric Scientist Development Program, 179 Presidential Medal of Freedom, 178, 342
Pennsylvania State University, 287, 381 Presidential Medal of Merit, 177
Perinatal Research Society (PRS), 469 Pressure, positive airway, 287, 292, 340
Phenotype, 122, 153, 210, 211, 221, 235, 241, negative, 293
247, 248 Primate, 79–91, 149, 237, 266, 269, 271, 374,
Philosophy of science, 244, 480 453, 492
Phosphatidylcholine, 289, 292, 295 regional primate centers, 374
Phototherapy, 306 Princeton University, Institute of Advanced
Phylogeny, 118, 423, 425 Study, 243
Physician–scientist, 168, 172, 176, 177, 179, Progesterone, 28, 34, 259, 269, 424
189, 333, 336, 337, 433, 469 Programming, 153, 219–221, 223, 249,
Physiological Society, Great Britain, 53, 54 297, 456
Physiology, early development, 113–129 Proopiomelanocortin (POMC), 270
Pig, 12, 18, 27, 28, 49, 74, 85–87, 149, 183, Prostacyclin, 102, 246, 262, 311
184, 193, 194, 236, 261, 264, 391, Prostaglandins, 70, 71, 74, 102–104, 260–262,
393, 395, 400, 492, 502, 505 269, 297, 310, 397, 401, 424, 429,
Placenta 445, 506
artificial, 192, 370 Proteinomics, 480
circulation, 24, 46, 68, 146 PRS. See Perinatal Research Society
classification, 137 (PRS)
cotyledon, 31, 154 Psychomotor development, 404
countercurrent exchange, 149 Puériculture, 330
electrical potential, 457 Pulmonary
insufficiency, 197 circulation, 66, 68, 74, 97, 100, 101,
intervillous flow, 149 103–106, 114, 261, 500, 501,
intervillous space, 137, 139, 144, 149, 503, 504
150, 404 disease, 216
maze, 156 hypoplasia, 354
morphology, classification, 142, 143, 145 surface tension, 287
pathology, 15, 154–156 surfactant, 281, 287, 288, 291, 292, 294,
placental exchange, 10, 11, 23, 33, 79, 146, 296, 351, 425, 486
149, 150, 311, 382 Tokyo-Akita, 290
pressures, 150
respiratory gas exchange, 33, 47, 83, 380
Pneumocytes, type II, 292 Q
Polar Medal, 299 Queen’s University, Belfast, 355
Polycythemia, 305
Polyhydramnios, 15, 154
POMC. See Proopiomelanocortin (POMC) R
Ponderal index, 196, 198, 213, 220 Rabbit, 12, 17, 23, 28, 72, 74, 87, 149, 183,
Popperian epistemology, 479 187, 193, 236, 260, 265, 269, 281,
Porpoise, 193 296, 347, 395, 450, 501–503
Potassium channels, 105 Radcliffe Infirmary, 52, 54, 56, 57, 59,
Potter’s syndrome, 354 99, 347
Pregnancy, 7, 10, 12, 23, 32, 73, 74, 85, 137, Radcliffe Observatory, 44, 56, 57, 99
144–146, 148, 153, 183, 188, 197, Radiation, 59, 124, 169, 211, 237
198, 213–214, 216, 223–224, 237, Radio-angiography, 30
530 Subject Index

Rat, 17, 72, 74, 87, 118, 129, 148, 190, 191, medicine, 367, 430
193, 194, 221, 236, 260, 265–266, New Zealand, 299
285, 342, 450, 492 Royal Victoria Hospital, Belfast
Regius Professorship of Medicine, 50 Royal Victoria Hospital, Montreal, 291
Renaissance, 48, 49, 114, 138, 189, 350, RSPD. See Reproductive Scientist
481, 485 Development Program (RSPD)
Renal disease, 216, 443
Renin angiotensin system, 221, 444, 449, 458
Reproductive Sciences, 469 S
Reproductive Scientist Development Program Salamander, 24, 242, 243
(RSPD), 179, 468 Sarah Morris Hospital (Michael Reese
Research Appeal Trust, 191 Hospital), 331
Respirator Scalp blood, fetal, 351, 403
BabyBird, 338 Schizophrenia, 207, 217–219
Bird® Infant Pediatric System, 338 Science
Bird Universal Medical, 338 scientific method, 46, 117, 127, 306,
negative pressure, 291, 335 478–480, 483
Respiratory distress syndrome, 105, 179, social construction, 478
281–296, 299, 335, 336, 370, Scottish Classical Association, 187
403, 425 Seal, 292, 297, 299, 509
Respiratory movements, fetal. See Breathing Sea urchin, 119, 120
movements, fetal Serotonin, 429
Resuscitation, newborn, 72, 88, 89, 502, 503 SGA. See Small for gestational age (SGA)
Retinopathy of prematurity, 340–344 Sheep, 9, 59, 73, 86, 99, 151, 173, 188, 236,
Retrolental fibroplasia (RLF), 287, 339–343 267, 289, 391, 444, 472, 492, 501
Rhesus (Rh) factor SIDS. See Sudden infant death syndrome
anti-Rh gamma globulin (RhoGAM), 304 (SIDS)
Rh incompatibility, 301, 305, 351 Small for gestational age (SGA), 8, 194–199,
RLF. See Retrolental fibroplasia (RLF) 327, 353, 355
Robert Wood Johnson Medical School, 245 Sociéte de Allaitement Maternalle, 329–330
Rockefeller Foundation Society for Gynecologic Investigation,
institute, 24 463–475
University, 31, 55 Society for Maternal-Fetal Medicine, 408
Rooming-in, 327, 332, 335 Society for Pediatric Research, 469, 486
Ross Conference on Pediatric Research, 372 Society for the Study of Foetal Physiology,
Rothamsted Experimental Station, 169 471, 472
Rotunda Hospital, Dublin, 402 Society of Foetal Physiology, 427
Royal College of Obstetricians and Sodium bicarbonate, 87, 91, 291
Gynaecologists, 19, 332, 340, 370, Somatomammotropin, 351
408, 430 Sorrento Maternity Hospital,
Royal College of Paediatrics and Child Birmingham, 331
Health, 293 Spastic diplegia, 82, 217
Royal College of Physicians, 48, 58, 191, Spina bifida, 217, 268
387, 430 Spirits
Royal College of Surgeons, Edinburgh, 140 animal, 46
Institute of Basic Medical Sciences, 261 natural, 46
Royal Commission, 52–54, 167, 168, 173 vital, 46, 138
Royal Faculty of Physicians and Surgeons, St. Bartholomews Hospital Medical
Glasgow, 30 College, 262
Royal Hospital for Sick Children, 198 St. Giles pub “Eagle and Child”, 64
Royal Oak Pub, 99 St. Mary’s Hospital Medical School, 17, 20,
Royal Postgraduate Medical School, 171 71, 292
Royal Society St. Thomas’ Hospital Medical School, 9,
Edinburgh, 19, 187 10, 28
Subject Index 531

Städt Frauenklinik und Umbilical circulation

Hebammenlehranstalt, 351 blood sampling, 352
Stanford University, 395, 486 cord, 12, 16, 18, 26, 29, 47, 68, 70, 73, 79,
Starling resistor, 102, 103 83, 87, 88, 101, 113, 138, 139, 154,
Starvation, Nazi-inflicted, 212 350, 351, 387, 388, 391, 392, 402,
State University of New York, Downstate 403, 445
Medical Center, 385 cord compression, 403
Stazione Zoologica di Napoli (SZN), 118–120 cord Occlusion, 88
Steroid biosynthesis, 260 United Kingdom Ministry of Health, 169, 330
Stillbirth, 85, 195, 214, 220, 407 United States
Stress Army Chemical Warfare Laboratories,
contraction stress test, 404 Edgewood Arsenal, 285
non-stress test, 352, 404 Centers for Disease Control, 173
Strong inference, 483 Department of Agriculture Research
Sudden infant death syndrome (SIDS), Service, 268
421, 505 Department of Health, Education, and
Surfactant, pulmonary, 281, 284, 285, 289, Welfare, 177, 370, 503
292, 295, 351, 425, 486 Food and Drug Administration, 173, 410
Surfactant-specific protein, 289 Human Subjects of Biomedical and
Synaptogenesis, 236, 237 Behavioral Research, 372
SZN., 237, 238 See Stazione Zoologica Marine Hospital Laboratory
di Napoli (SZN) of Hygiene, 173
Mental Health Act of, 175
National Commission for the Protection
T of, 372
Tanner scale, 198 National Research Council, 24
Tanner stages, 198 Office of Naval Research, 175
Testosterone, 265–267 Office of Scientific Research and
Thalassemia, Cooley’s anemia, 371 Development, 65
Thermoregulation Presidential Citizens Medal, 338
thermal neutral zone, 347 Presidential Medal of Freedom, 178, 342
thermogenesis, 346, 347 Public Health Service Laboratory, 173
Thromboxane, 102, 104, 261, 506 Service Research Program, 173
Tissue culture, 121, 354 University College, Dundee, 184
Tocodynamometry, 409 University of Adelaide, 394, 475
Tracheal fluid, fetal, 393, 395 University of Alberta, 426
Transcutaneous oxygen monitoring, 333 University of Auckland, 294, 299, 303
Transfusion, fetal blood, 303 University of Berne, 140
Transplacental exchange, 145–154 University of Birmingham, 170, 261
Trishydroxymethyl-aminomethane, 88, 502 University of Bochum, 427, 455
Trisomy, 352 University of Bologna, 114
Trophoblast University of Breslau, 121
cytotrophoblast, 140 University of Bristol, 387
syncytiotrophoblast, 140 University of British Columbia, 101, 309,
Twins, 15, 154, 155, 184 442, 449, 475
Twin to twin transfusion syndrome, 15, University of California Berkeley, 196
154, 155 University of California Davis, 199, 268,
395, 405
University of California Irvine, 393
U University of California Los Angeles,
Ulster Medical Society, 145 197, 262, 312, 333, 447, 458, 464,
Ultrasonography 474, 475
diagnostic, 196 University of California San Diego, 266,
Doppler ultrasound, 396, 406, 506, 509 289, 293
532 Subject Index

University of California San Francisco, 106, University of Newcastle upon Tyne, UK, 482
289, 299, 310, 333, 345, 372, 408 University of Nottingham, 451
University of Chicago, 19, 119, 128, 149, 184, University of Oklahoma, 270
243, 354, 504 University of Padua, 48
University of Colorado, 102, 196, 333, 382, University of Pennsylvania, 65, 85, 106, 383,
383, 404 484, 491
University of Copenhagen, 122, 199, 301 University of Pisa, 47
University of Dresden, 305 University of Prague, 143
University of Edinburgh, 66, 140, 209, 349 University of Reading, 471, 472
University of Florida, 97, 308, 309 University of Rochester, 129, 191, 391
University of Freiburg, 117, 124, 125 University of Rome, 114
University of Gothenburg, 430 University of Rostock, 15
University of Göttingen, 115, 482 University of Southampton, 220, 451, 475
University of Graz, 398 University of Southern California, 393, 466
University of Groningen, 398 University of St. Andrews, 184
University of Halle, 121 University of Sydney, 263
University of Hamburg, 16 University of Texas, Austin, 123, 243
University of Helsinki, 290 University of Texas, Southwestern, 485
University of Illinois, Chicago, 244 University of Toronto, 172, 292, 444, 447, 472
University of Jena, 13, 394 University of Tubingen, 117
University of Leeds, 17 University of Uppsala, 345
University of Leiden, 381 University of Uruguay, Montevideo, 403
University of Liverpool, Women’s and University of Utrecht, 16, 140
Maternity Hospitals, 267 University of Vermont, 154, 288, 339
University of London, 268 University of Vienna, 332
Bedford College, 21 University of Western Ontario, 198, 283, 383,
Gresham College, 50 398, 399, 427, 471, 473
Guy’s Hospital, 125, 189 University of Zurich, 283
King’s College Hospital, 189, 423 Usher regime, 91, 338
Queen Elizabeth Hospital Uterine contraction, 91, 339
for Children, 190 contraction stress test, 404
University College Hospital, 170, 293 non-stress test, 352, 404
University College, London, 21, 53, 54, oxytocin challenge test, 352, 404
170, 191, 242, 262, 300, 301, 383 Uteroplacental blood flow, 8, 382
University of Lund, 345 contraction stress test, 404
Bedford College, 23 non-stress test, 352, 404
Gresham College, 50 oxytocin challenge test, 352, 404
Guy’s Hospital, 125, 189 Uteroplacental circulation, 145–154
King’s College Hospital, 189, 422 Uteroverdin, 23
Queen Elizabeth Hospital for Uteroverdin, 24
Children, 191
University College Hospital, 171, 295
University College, London, 23, 53, 54, V
170, 191, 242, 263, 301, 302, 383 Vanderbilt University, 335, 368
University of Manchester, 154, 236, 340, 475 Van Slyke
University of Marburg, 344 manometric apparatus, 9
University of Medicine and Dentistry of New micromethod, 28
Jersey, 245 Vascular endothelial growth factor (VEFF),
University of Melbourne, 270, 342, 400 146
University of Miami, 381 Vena cavae, 26–28, 310
University of Michigan, 124 Ventilation
University of Missouri, 199 negative pressure, 291
University of Montevideo, 150 positive pressure, 72, 79, 89, 91, 291, 344,
University of Newcastle, Australia, 443 502, 503
Subject Index 533

Venus, transit of, 56 White Hart Pub, 450

Veratrum alkaloids, 64, 65, 499, 500 White House Conference on Child Welfare
Veratrum californicum, 268 Standards, 349
Viability, fetal, 70, 370, 372 William Harvey Research Institute, 262
Vitalism, 126, 127, 184, 186, 242 World Association of Perinatal Medicine, 469
von Willebrand factor, 222 World Fair, New York, 331
World Health Organization, 84, 175, 194, 195
Expert Group on Pre-Maturity, 194
W Wright State University, 197
Warburg apparatus, 97, 119
Washington University, St. Louis, 295
Weismann barrier, 117 X
Wellcome X-rays, 25, 59, 74, 123, 124, 301
foundation, 261
trust, 130, 340
trust institute, Cancer Research and Y
Developmental biology, 130 Yale New Haven Hospital, 332, 335
Whale, Blue, 193 Yale University, 33, 332, 393, 402, 469