the lost Y chromosome, she was effectively a piece of her brother from whom she was issued.

These facts of human genetics can appear a little too theoretical, and the question must be asked whether common sense can recognize as such a tiny human being. If very early, only the scientist aided by refined techniques, can tell. If, let us say, at two months everybody knows, and has known for thousands of years.

At two months of age, the human being is less than one thumbs length from the head to the rump. He would fit neatly into a nutshell, but everything is there hands, feet, head, organs, brain-all are in place. If you look very closely, you would see the palm creases, and if you were a fortune teller, you could read the good adventure of that person. Looking still closer with a microscope, you could detect the finger prints like Sherlock Holmes-every document is available to give him his national identity card!

The incredible Tom Thumb really does exist. Not the one of the fairy tale, but the one each of us has been. For it is from this true story that the fairy tales were invented. If Tom Thumb's adventures have always enchanted the children, if they can still evoke emotion in grown-ups, it is because all the children of the world, all the grown-ups they have turned into, were one day a Tom Thumb in their mother's womb.

But can we scientists accept these fairy tales? The truth is indeed that Nature itself does. For instance, abortion is a normal process in imperfect mammals called marsupials. They have a special pouch n othe abdomen, conveniently accommodated to nurture the little. In the giant kangaroo, the abortion occurs at the same stage as the little Tom Thumb in man, and is roughly the same size. The aborted fetus then climbs into the fur of its mother to reach the pouch. The bewildering fact is that the kangaroo mother will let him do so, although she would not allow any other kind of animal drop in! If the poor brain of a female kangaroo can recognize the tiny creature as a kangaroo being, there is no wonder that geneticists can safely assure you that Tom Thumb is indeed a true human being.

From molecular genetics to comparative reproduction, nature has taught us that from its very beginning the "thing" we started with is a member of our kin. Being its own, human by its nature, never a tumor, never an amoeba, fish or quadruped, it is the same human being from fecundation to death. He will develop himself if the surrounding world is not too hostile. And the sole role of medicine is to protect the individual from accidents as much as possible during the long and dangerous road of life.

Senator BAYH. Thank you, Dr. Lejeune. [General applause.]

Senator BAYH. For the sake of those of you who have not been here before, I will repeat what I said previously. We have some very intricate matters to discuss. They are, indeed, matters of life and death. They should not be and are not going to be decided by an applause meter. What we have found historically in committee hearings, inasmuch as both sides of this issue are represented, as they should be, by witnesses and by members of the audience, that insisted of directing our attention at what is being said here and trying to stimulate our intellect, each position on this issue tries to compete with one another to see who can command the longest and loudest amount of applause.

I hope that that observation will be accepted by those who are here, and it will not be necessary to repeat to you that I do not think applause helps us in our process of deliberation.

Dr. Lejeune, we appreciate your testimony.

May I ask that we get Dr. Liley's, and then we can have a discussion back and forth between you gentlemen and responses to questions from my colleagues and myself.

Dr. Liley.

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STATEMENT OF DR. ALBERT W. LILEY, KCMG, POST GRADUATE SCHOOL OF OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF AUCKLAND, NATIONAL WOMEN'S HOSPITAL, AUCKLAND, NEW ZEALAND

Dr. LILEY. Thank you.

Mr. Chairman and members, my name is Albert William Liley. I hold qualifications and have been trained in neurophysiology, obstetrics, and neonatal pediatrics. I hold the appointment of research professor in perinatal physiology at the Postgraduate School of Obstetrics and Gynecology in Auckland.

Like Dr. Lejeune, I also owe a debt to the United States of America, having spent a year of sabbatical leave in the United States on an international post doctoral fellowship of the U.S. Public Health Service and at the expense of the American taxpayer.

For 17 years, I have been engaged in work which would be most accurately described as fetal pediatrics. In 1963, I developed a technique by which babies, particularly Rh babies, who were beyond the aid of conventional thrapy, could be transfused in the uterus to tide them over to a deliverable maturity. And in this situation, it is apparent that the fetus may be ill, can receive diagnosis and treatment, just like any other patient.

I regard it as a bitter irony that just when, for the first time, the fetus arrives on the medical scene who can be a patient, ill, receive diagnosis and treatment, just like any other patient, there should be such strenuous efforts to make him a social nonentity. And I would find it as a physician extraordinarily arbitrary if I were required to regard some fetuses as patients and to treat them properly and to deny existence to others.

The diagnosis and treatment of fetal illness constitutes, of course, an invasion of fetal privacy, but it has presented to us both the opportunity and the techniques to observe the fetus in utero. These observations, initially obtained by techniques with which most people are not particularly familiar-for instance, ultrasound, electrical recording, X-rays and so on. But this does not for a moment deny the reality any more than, for instance, the fact that one of us here today might have tuberculosis or cancer would be any less real for the fact that it required a microscope or X-ray to diagnose it.

The techniques we developed for diagnosis and treatment of one particular illness in the fetus have now been extended to other diseases, to sorting out an assortment of problems in fetal and pregnancy physiology, as I have mentioned have allowed us to build up a picture of fetal environment and fetal behavior. I must concede immediately that the majority of observations have been made after about 16 weeks of gestation.

This has been forced upon us by two considerations. First, this has been the range in which our present state of knowledge or ignorance of fetal medicine has meant that we have been able to offer something to the fetus in the way of active treatment of illness. And it has also been forced upon us by limtiations of current techniques of investigation, for instance X-ray.

Now, however, we do have at our command other diagnostic techniques, for instance ultrasound, which are applicable before X-ray is

suitable. And also, we have been able to observe fetuses. There are classic studies in the United States, for instance, by Davenport Hooker on the short life of the miscarried baby. And it is apparent that the observations we have made in mid-pregnancy and late pregnancy are but part of a spectrum which starts earlier in pregnancy. Where appropriate, I will refer to what we know of earlier fetal life. On the physiological side, the picture that emerges is very different from the traditional idea that the fetus in utero is a placid, dependent, fragile, nerveless vegetable. There is no doubt whatsoever that in physiological terms the fetus is in command of the pregnancy. It is the fetus who is responsible for the endocrine or hormonal success of pregnancy. It is the fetus who solves the homograft problem. In any outbreed population, such as the human population, mother and her fetus are inevitably immunological foreigners who could not exchange skin grafts, who could not be safely given a blood transfusion one from the other. Yet for the whole of pregnancy, they must tolerate each in a parabiosis rather than a parasitic state, and it is the fetus who is responsible for this solution of this homograft problem, which I could point out in terms of surgical transplantation of organs is one of the major challenges to surgical physiologists.

It should be a satisfaction to all of us, Mr. Chairman, that we individually solved this problem ourselves before we were born, or we would not be here now.

The fetus is also responsible for the initiation of labor. In other words, the onset of labor is a unilateral decision by the fetus, that we each chose our own birthdays, unless our mother's doctor with good cause thought he had better reason than we did to know when we should be born. I could say, in an idiom perhaps more familiar to Americans, that the onset of labor is a unilteral declaration of independence of the fetus.

But independence, of course, immediately raises the question of whether fetal life is dependent, whether it is self-sustaining, or is only a partial existence because it is not truly independent. Of course, all the state of the fetal world demonstrates is that it is life in one particular physiological state of circumstances, just as with adults the physiological environment in which we can live is ridiculously circumscribed. We think that humans have conquered the poles and space and so on; in fact, all they have developed is the technology to take a small parcel of their own environment, their own life support system with them. So also the fetus has his own life-support system before birth, his membranes and placenta which, when he no longer needs them, at birth, in a different physiological environment, they are discarded.

The picture we have built up of fetal behavior also differs very much from the traditional picture of a dark and silent world, with perhaps some aimless kicking that begins about the 16th or 20th week of pregnancy. This movement in itself is interesting. It is known in English and American, also, I think, Mr. Chairman, as "quickening," coming from the old Anglo-Saxon "quick," meaning alive or living.

But, in point of fact, this quickening is only a perception of movements by the mother rather than the beginning of fetal movement. The fetus has been moving ever since he had muscles and arms and

legs to move, about 42 to 46 days of gestation. But as these kicks are not felt in the uterus but only on the abdominal wall, it is not until some 16 to 20 weeks of gestation that these movements are, in fact, first perceived by the mother.

We know that the early fetus is in continuous movement in the uterus. He is far from lying still. He is very active. But, as I said, these movements are not perceived by mother. We know that the fetus is responsive to touch. His pattern of movement changes throughout pregnancy, but he is responsive to touch, and that in late pregnancy it is the fetus who determines which way he will present in pregnancy, or lie in pregnancy and present in labor. In other words, fetal comfort determines fetal position.

Now in obstetrics we have abandoned the technique of version, or changing babies into what obstetrically might be a more convenient position, because now we are not so arrogant as before as to think we know better than the fetus how he is most comfortable. So, in selecting a position of comfort in late pregnancy, the fetus may have chosen a position which is difficult or dangerous or impossible for delivery, and in this regard may be accused of lack of foresight. But this, of course, is a trait not unknown in adults.

The fetus is also responsive to pain. We from time to time for diagnostic and therapeutic procedures have to stick needles into fetuses to inject cold and concentrated solutions. The fetus reacts violently to these stimuli, which we know are painful in adults, which we know are painful in children, and to judge from his behavior are also painful to the newborn. And I think it is at least charitable to consider that they are also painful for the fetus.

We also know that the contractions of labor produce violent reaction from the fetus. But it is an interesting measure of the manner in which one can be adultocentric, if there is such a word, in one's view of these problems, to remember that in all the discussions that have taken place on pain relief in labor, the only pain that has ever been considered has been that of mother. The question of whether the fetus might also be better for some pain relief in labor has not been considered.

The fetus is responsive to temperature change in its surroundings before birth. Although normally the range of temperature change is small, if we irrigate the cavity of fluid in which he lives with cold saline solution, the fetus shows appropriate motor and circulatory

responses.

Nowhere does the idea of the fetal life being a time of quiescence die harder than in the idea that the inside of a pregnant uterus is a dark and silent world. In point of fact, neither of these is true, and the fetus is responsive to both light and sound before birth. As great a neurophysiologist as Sir Charles Shearington could speak of the miracle of the human eye developing in darkness for seeing in light, and the miracle of the human ear developing in silent water for hearing in vibrant air. Both of these, in fact, are quite fallacious.

It is possible using fiber-optic conduit and photomultiplier to measure light intensities in the uterus and the change in light intensity when ordinary room lights are switched on. And we now suspect that the diurnal rhythm in the onset of labor or rupture of mem

branes the fact that more women go into labor at night than by day may, in fact, be a fetal rhythm determined by the effect of light on the fetal hypothalamus through his eyes.

We also know that the fetus is responsive to sound before birth, that if we have a baby lined up under an image intensified for some diagnostic or therapeutic procedure, when somebody, mother included, speaks, or somebody drops something on the floor, this will startle the fetus in utero, just as it does the baby after birth in the incubator. And, in fact, we have had the fetuses of deaf-mute mothers, perhaps with deaf-mute husbands such people tend to be thrown together, common sympathy. And, then, of course, the serious question arises, mother and father very concerned as to can their baby hear. We have been able to reassure such couples as early as 25 weeks gestation-we simply have not looked earlier-but we have been able to reassure them that the fetus was, in fact, responsive to sound, that he could hear.

Just out of interest, the loudest sound levels to which the fetus in utero is exposed are up around th 85 to 90 decibel mark, which is about the intensity of sound in a busy city street.

We know that babies swallow their amniotic fluid before birth, that they do this from at least as early as 8 weeks' gestation, and that if we make their fluid taste pleasant or taste nasty with oily contrast medium, the babies very decidedly drink less. They quit drinking if you make their fluid taste unpleasant, and if their fluid is sweetened with saccharin, they usually double their swallowing rate, the rate at which they drink their fluid, although interestingly a small minority of babies drink decidedly less after their fluid is sweetened with

saccharin.

We are interested to follow these children up, because there are some people, myself included, who do not find saccharin in concentration sweet but intensely bitter. This is a well known trait, and we suspect that we have already observed this in utero already, but we are interested to follow these children until they are older and check this phenomenon.

It is not at all uncommon on antenatal radiology, on X-rays, to notice fetuses sucking their thumbs. We have demonstrated this by X-ray as early as 25 weeks' gestation. And, of course, some sucking has been photographed in the 9-week abortus.

It is also apparent that behavior traits that are apparent after birth have also been demonstrated before birth. For instance, everyone knows that some babies after birth are simple and easy to feed; they are vigorous feeders on the breast or the bottle, where there are other babies that very much irritate nursing staff and new mothers by being dainty, tedious, and slow feeders. We have, in fact, been measuring fetal swallowing rates in pregnancy. Some babies drink at a much higher rate than others and some at a much slower rate. And interestingly enough, these rates correlate very well with independently assessed feeding performance in the nursery after birth. In other words, the babies who are the good drinkers out of the uterus were good drinkers in it, and the ones who were the tedious feeders out of it were the tedious feeders in it.

It is apparent to me, Mr. Chairman, that from my care, the responsibility I have for the care of babies before birth, and from the