PEDIATRICS 
DISEASES OF INTRA-UTERINE LIFE ON 
THE PART OF THE MOTHER. 
By EGBERT H. GRANDIN, M. D. 
Consulting Gynecologist to the French Hospital, Etc., New York. DISEASES OF INTRA-UTERINE LIFE*—ON THE PART 
OF THE MOTHER. 
By Egbert II. Grandin, M. D., 
Consulting Gynecologist to the French Hospital, Etc., New York 
THE portion of this topic assigned to me by your President 
is that which relates to the effect of disease of the child- 
bearing woman on the fetus. When requested by him to 
prepare a paper on this subject, I confess I little realized the ob- 
scurity which surrounds it, nor the task of Sisyphus I had under- 
taken in endeavoring to sift from the mass of theory enveloping it 
sufficient that is known as fact to justify me in appearing before 
you at all. My own researches in literature and those which my col- 
league, Dr. Marx, has undertaken in my behalf teach me that very 
little of a positive nature is recorded bearing on this all-important 
subject. I take it that I am not desired to rehearse for you well 
authenticated facts, but that I am expected, as a scientific man 
reading to a scientific body, to endeavor to add at least a mite to 
given knowledge. After summarizing for you the little of a defi- 
nite nature which I find recorded in regard to disease of the woman 
as affecting the fetus, I trust, when I venture, as I needs must, to 
theorize you will bear in mind the fact that it is in no spirit of dog- 
matism, but because I must theorize if I speak at all. 
I shall not waste your time in dwelling on the well-known effect 
of high maternal temperature on the fetus, nor shall 1 mention 
more than thus cursorily the fact that a not infrequent result of such 
constitutional disturbance is the shedding of the ovum. Neither 
shall I refer at all to the vexed question as to whether impressions 
of the mother may be transmitted through the nervous system to 
the fetus—the so-called doctrine of maternal impressions. One 
would think that this latter doctrine, whatever the occasional strong 
proof offered, had long ago been exploded when it was certified that 
there existed no communication by means of nerve filaments be- 
tween the woman and the fetus. I take it that I shall best suc- 
ceed in interesting you, if perchance I do so at all, by dwelling in 
the first place on the acute and chronic diseases which experimental 
research and actual experience have proven in some way or another 
reach the fetus when the woman is affected, and in the second 
place by theorizing as to how these diseases are transmitted. 
It is only in the lifetime of most of us here present that bacteri- 
* Read by invitation before the Medical Society of the State of New York, January z8th, 1896, 2 
PEDIATRICS. 
ological research has enabled us to speak at all dogmatically in re- 
gard to the transmissibility of disease from the woman to the fetus. 
This is one of the fruits of the advanced stage where the science of 
medicine finds itself to-day, and who can predict the wonderful pos- 
sibilities of research along the same line in the not distant future? 
Experimentation on gravid animals and sparse clinical observation 
in the case of woman prove that most of the acute infectious dis- 
eases may be transmitted from woman to the fetus. Thus, to 
specify briefly certain of the individual diseases: Variola can un- 
doubtedly be transmitted. Cases are recorded where the woman 
has had this disease and the fetus has been born bearing pock- 
marks; other cases where the woman has been exposed to the 
disease, has escaped it and yet the fetus has been born with it. 
Strangely enough, and something almost impossible to understand, of 
twins, one has been covered with pock-marks and the other not; and, 
more curious still, immunization of the woman by vaccination has 
failed to protect the fetus. 
Transmission of measles has only exceptionally been noted, but 
then we must remember that this disease is one which rarely affects 
adults, since the vast majority have suffered from it in infancy. 
Yet the researches of Dr. Marx have resulted in six cases being 
found on record. 
Intra-uterine infection by scarlet fever is unquestioned, and the 
same holds true for erysipelas. In regard to the latter affection, it 
should be noted that in one recorded casethebacillus was found inthe 
sub-cutaneous tissue of the fetus, and yet not in either the placenta 
or the cord. Three cases have been recorded where remittent fever 
affected the fetus, in one the spirilla having been found. In two of 
the cases, one of which was witnessed by Dr. Marx, the woman had 
a distinct sensation of violent motion on the part of the fetus as 
though it were having a rigor, shortly after she had had a chill. 
There is but one undoubted case on record of transmission of 
tuberculosis. This is not unexpected when we remember that mark- 
edly tubercular women are not prone to conceive. Septicemia is 
transmissible, the cases where this has been observed being few, but 
then, since the development of the science of bacteriology, we have 
rarely had the opportunity of seeing instances of sepsis developing 
before labor, even as gradually these cases are becoming more and 
more infrequent after labor, as the fact is impressed on students that 
it is an avoidable disease where asepsis characterizes obstetric 
practice. 
The facts in regard to syphilis are too well known to call for PEDIATRICS 
3 
comment here. Indeed more is fact in reference to this scourge, 
and has been such for long, than in regard to the transmissibility of 
any other disease. So far as concerns our present purpose, sufficient 
the statement that a syphilitic woman, if she conceive at all, will 
necessarily infect the fetus; and, further, if she become syphilitic 
whilst bearing the fetus, the chances are that the latter will become 
infected. 
In short, so far as my researches have carried me, there is but 
one acute disease which the woman is not able to transmit to her 
child in utero, and this is anthrax. I can find no case on record 
where this disease has been transmitted, and the positive opinion is 
justified that such transmissibility has never been verified. 
Having established the fact of the transmissibility of disease, 
we pass to the important question, and the one where theory of ne- 
cessity steps in, as to how the transference is effected. 
Broadly speaking, disease is carried throughout the human body 
either through the medium of the blood vessels or by the lymphatic 
system. That is to say, whatever the source of original entrance of 
the germ, whether by the alimentary canal or the respiratory tract, 
it is disseminated throughout the body either through the medium 
of the blood or the lymph stream. Now, in the case of the fetus 
in utero, since so far as we can determine it neither breathes nor 
eats, infection must reach its system by either blood or lymphatic 
stream. Recalling for a moment the anatomy of the placenta and 
the well-established facts in regard to the connection of the maternal 
system to the fetal, we see that direct transmission of disease from 
the woman to the fetus by either method is an impossibility, since 
there is no connection between the blood or lymphatic system of 
the one and that of the other. The placenta intervenes between the 
woman and the fetus, and direct interchange of material is pre- 
cluded by the anatomical relation of placenta to uterus. The fetus, 
of course, receives its nourishment from the maternal blood, but in- 
directly, through the interposing medium of the placenta. As far 
as researches testify, it is probable that interchange of material oc- 
curs in the intervillous spaces which constitute the boundary line 
between maternal decidua and fetal. Here the activity of the 
blood current is very marked and the conditions which favor inter- 
change are most favorable. Either, then, material, nutrient or toxic, 
reaches the fetus through the medium of these spaces by simple 
transfusion, or else by migration of leucocytes. It seems tome that 
in the light of modern data in reference to the germ-bearing capac- 
ity as well as germ-destroying faculty of the leucocytes we most 4 
PEDIATRICS. 
rationally look to them as the carriers of disease from the woman to 
the fetus. This explanation, further, will be seen best to accord 
with certain facts which have been established in regard to condi- 
tions under which disease is apt to reach the fetus and as to when 
it is not. 
All investigators into the question of the tranference of disease 
from the woman to the fetus are agreed as to the important role 
played by the placenta and the intervillous spaces. It has been ac- 
curately established that a sine qua noti for the transmission of dis- 
ease is a diseased state of the placenta. Take, for instance, certain 
facts established in reference to syphilis. It has been noted that 
where a woman becomes infected at the time of copulation, syphilitic 
foci often develop in the maternal portion of the placenta leading 
to a placental endometritis. Thus, then, a healthy ovum becomes 
infected because of the similar infection of the placenta. Again, it 
has been established that where the woman is syphilitic before con- 
ception occurs, or else where she becomes infected shortly after con- 
ception, where the placenta remains unaffected, the fetus escapes, 
and vice versa. Again, it has been proven that where the woman 
does not become infected until after the seventh month of gestation 
the placenta escapes infection and the fetus as well. All these 
facts go to prove that a healthy placenta offers a barrier to the trans- 
ference of disease from the woman to the fetus. Similar investi- 
gations in regard to the placenta in case of other diseases from 
which the woman is suffering at the time of conception, or which 
affect her during gestation, certify to the truth of this assertion in 
reference to the safeguard against the entrance of disease into the 
fetus offered by the interposition of a healthy placenta. 
The theory, then, which fits known facts, and which we must at 
the present day accept, is that which credits the leucocytes with 
transmission of disease from the woman to the fetus. Given an 
instance where the woman is in health at conception, and for a cer- 
tain period afterwards, and the chances are that the placenta inter- 
vening between woman and fetus is healthy. Now let this woman 
become diseased and at once the leucocytes in her blood system 
carry the infection to the intervillous spaces. Here they are met by 
the barrier against disease established by the healthy placenta. This 
placenta contains healthy leucocytes with the property of resisting 
the entrance of diseased germs. The phagocytic action of these 
healthy leucocytes comes into play, destroys at once the leucocytes 
bearing disease, and thus the fetus is protected. 
Given, on the other hand, a woman diseased at the time of con- PEDIATRICS. 
5 
ception, or becoming so shortly afterwards, that is to say, at a period 
when the placenta is in the course of early formation, then either we 
have at the outset a diseased placenta or one which becomes dis- 
eased as it is forming. Such a placenta contains either no healthy 
leucocytes or else they have but feeble resisting powers. The bar- 
rier interposed by the placenta is, therefore, ineffective to an abso- 
lute degree, or else the leucocytes within it resist feebly or strongly, 
according to the intensity of the disease process endeavoring to gain 
access from the side of the woman. In this latter event disease is 
transmitted to the fetus, because the disease-bearing leucocytes 
from the side of the woman are stronger than and overcome the 
leucocytes in the placenta. 
The question we are considering is possibly not so difficult of 
solution where the woman is affected by a disease, such as tubercu- 
losis or syphilis, at the time of conception. If this woman conceive 
at all, it is not improbable that the ovum at the time of insemmina- 
tion contains the germs of such disease, or, at any rate, in case the 
ovum should perchance be healthy, then we might consider that the 
uterine mucosa, where the placenta must engraft itself and develop, 
is diseased. In such an event the fetus may be said to be diseased 
from its very start toward life, or in life, since we must look upon 
the germ of life as present from the very date of insemmination. 
Such a fetus dies early and is shed early, from the very fact of 
death due to the disease from which the woman is suffering. The 
data we possess in regard to early miscarriage prove its great fre- 
quency under the condition we are considering. Here disease is 
transmitted to the fetus from the woman, because of the existence 
of such disease in the woman prior to conception. The limitations 
of our, as yet, finite powers of observation and analysis do not allow 
us to prove this assertion, for who can examine the ovum at a stage 
when it has but become endowed with life, and who, as yet, is able 
to do more than theorize in reference to the constitution of the germ- 
inal area, whether it can contain the germ of disease and still grow 
or not ? All that we are justified in doing, therefore, is to theorize, 
and I can but submit that the theory I have stated rests on a basis of 
probability. 
The limitations of theory are about as absolute when we face 
the question of the transmission to the fetus of disease which the 
woman has acquired during gestation. In such an event, as we have 
noted, a sine qua non appears to be the presence of a diseased pla- 
centa. We must assume then that, in instances where transmission 
occurs, the soil in which the placenta has developed was diseased 6 
PEDIATRICS. 
before conception, not sufficiently to lead to a placentitis inconsist- 
ent with fetal development, but yet of a high enough grade to in- 
terpose a very feeble barrier to the leucocytes from the side of the 
woman bearing the germs of the disease which has attacked her 
during gestation. When we remember the frequency with which 
the milder grades of endometritis are met with in women who 
nevertheless conceive and carry the fetus to term, it is not improb- 
able that the vast majority of women do not possess an ideally 
healthy placenta; that is to say, that in the average woman the con- 
ditions exist at the placental site which enable the transmission of 
disease from woman to fetus to occur. 
Such, Mr. President, are the slender facts tinctured with weighty 
theory which I am able to offer. I regret that much thought and 
research have not enabled me to penetrate deeper the gloom which 
enshrouds this important topic. But, even as we note the growth 
and the death of the flowering plant without the ability to solve all 
the elements which enter into the marvel, even so, when endeavoring 
to elucidate a question dealing with a greater marvel still—the his- 
tory of life in man before life, such as we know it, begins—can any 
one wonder that theory prevails and fact has stringent limitations? Published on the 1st and 15th of the Month, $2 or 8 Shillings a Year. 
PEDIATRICS 
An Illustrated Semi-Monthly Devoted to the 
Diseases of Children. 
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EDITOR : 
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EDITORIAL STAFF: 
Medicine. 
A. Jacobi, M. D., New York, Clinical Professor of 
Diseases of < hildren in Columbia College. 
Frederick Forchheimer, M.D., Cincinnati, Ear-Presi- 
dent of the American Pediatric Society, and Pro- 
fessor of Diseases of Children in the Medical Col- 
lege of Ohio. 
Surgery. 
Henry R. Wharton, M. D., Philadelphia, Surgeon 
to the Children's and the Presbyterian Hospitals. 
Frederic S. Eve, F. R. C. S., Eng , London, Surgeon 
to the London Hospital and to the Evelina Hospital 
for Children. 
Lambert H. Ormsby, M. D., F. R. C. S. I., Dublin, 
Surgeon Meath Hospital and National children's 
Hospital. 
Orthopedics. 
Henry Ling Taylor, M. D., New York, Assistant to 
the Hospital for Ruptured and Crippled. 
Frederic R. Fisher, F. R. C. S., Eng., London, Senior 
Surgeon to the National Orthopedic Hospital, and 
late Surgeon to the Victoria Hospital for Children. 
Therapeutics. 
Reynold Webb Wilcox, M. D., New York, Professor 
of Therapeutics in the Post-Graduate Medical 
School, and Physician to St. Mark's Hospital. 
John Thomson, M. I)., Edinburgh, Extra Physician 
Royal Hospita1 for Sick Children, and Lecturer on 
Diseases of < hildren, Edinburgh School of Medicine. 
Dawson Williams, M. I)., London, Physician to the 
East London Hospital for Children. 
Teratology. 
Egbert H. Grandin, M. D., New York. Ex-President 
of the County Medical Society; Consulting Obstetric 
Surgeon to the Mat'err.ity Hospital, and Gynecolo- 
gist to the French Hospital. 
J. W. Ballantyne, M. D., Edinburgh, Lecturer on 
the Diseases of Infancy and Childhood, Minto 
House; and Physician for Diseases of Children, 
Cowgate Dispensary. 
Gastro-Enteric Diseases. 
Morris Manges, M. I)., New York, Physician to 
Mount Sinai Hospital, and Editor of “Ewald's 
Diseases of the Stomach." 
J. Boas, M. D , Berlin, Editor of the “Archiv fur 
Virda u u ngs-kra nkheiten.' ’ 
Genito-Urinary Diseases. 
Frederic Russell Sturgis, M. D., New York, Visit- 
ing Surgeon to the City Hospital. 
Fancourt Barnes, H. D., London, Consulting Phy- 
sician to the British Lying-In Hospital, St. George's 
Hospital, Seamen's Hospital and East London Hos- 
pital for Children. 
Neurology. 
Joseph Collins, M. D., New York, Physician to the 
Hospital for Nervous Diseases. 
James Taylor, M. D., London, Senior Assistant Phy- 
sician to the National Hospital /or the Para yzeil. 
Materia Medica. 
Henry H. Rusby, M. D., New York, Professor of 
Materia Medica and Botany in the College of Phar- 
macy. 
Laryngology and Otology. 
Wm. C. Glasgow, M. D., St. Louis, Professor of 
Laryngology in the Missouri Medical Co lege. 
Arthur H. Cheatle, F. R. C. S., London, Assistant 
Surgeon to the Royal Ear Hospital and Aural 
Department of King's College Hospital. 
Max Thorner, M. D., Cincinnati. Professor of Lar- 
yngology and Otology, Cincinnati College of Medi- 
cine and Surgery; and Aurist and Laryngologist to 
the Cincinnati Hospital. 
Peter McBride, M. D., Edinburgh, Aural Surgeon 
and Laryngologist, Royal Infirmary; and Lecturer 
on the Diseases of the Ear and Throat, Edinburgh 
School of Medicine. 
Dermatology. 
James Nevins Hyde, M.D.,Chicago, Professor of Skin 
and Venereal Diseases in Rush Medical College. 
Leslie Phillips, M. D., Birmingham, England, Sur- 
geon Birmingham and Rlidland Skin and Lock 
Hospital. 
Ophthalmology. 
Myles Standish, M. D , Boston, Ophthalmic Surgeon 
to Carney Hospital and to Massachusetts Charity 
Eye and Ear Infirmary. 
William Arthur Brailey' M. D., London, Ophthal- 
mic Surgeon to Evelina Hospital for Children, and 
Guy's Hospital. 
Pathology and Bacteriology. 
Henry Ashby, M. I)., Manchester, England, Physi- 
cian Manchester General Hospital for Children; 
and Lecturer on Diseases of Children, Owen's 
College. 
Alfred Lingard, M. D., Poona, India, Professor of 
Bacteriology, Science College. 
Physiology. 
C. S. Sherrington, M. D., F. R. S., Liverpool, Eng- 
land, Holt Professor of Physiology, University 
College. 
Psychology. 
T. Telford-Smith, M. D., Lancaster, England, resi- 
dent Medical Superintendent,Royal Albert Asylum. 
Tropical Diseases. 
Major H. P. Birch, Quetta, India, Surgeon. VOL 1 N9I 
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