Table Of ContentClinics in Developmental Medicine No. 24
Locomotion from Pre- to
Post-natal Life
How the newborn begins to acquire
psycho-sensory functions
BY
Andre-Thomas and S. Autgaerden
PREFACE BY
R. C. Mac Keith
27s. 6d. or $4 1966
Published by the Spastics Society Medical Education and Information
Unit in Association with William Heinemann Medical Books Ltd.
First published in 1963 by Masson et Cie., Paris,
under the title La Locomotion de la Vie Foetale
a la Vie Post-Natale. The Appendix to this edition
originally appeared in La Presse Medicale, 71,
1761, as a paper entitled Audibilite Spontanee de la
Voix Maternelle, Audibilite Conditionnee de toute
autre Voix.
Printed in England by THE LAVENHAM PRESS LTD., Lavenham, Suffolk
Preface
Andre Thomas was one of the great explorers in the terra incognita of infant
neurology. He had a career in neurology of adults and after that a second career
studying the behaviour and neurology of the neonate and the infant. He was moved
to embark on his second career by the 'divine discontent' aroused by being asked to
examine a child and feeling he did not know what were the normal responses of a
baby, and by the interest he felt on observing the complex adaptive responses of an
anencephalic.
Our first Clinic was a translation of an earlier work of Andre Thomas. It has gone
all over the world. We are privileged to publish this, his last work, and we are including,
from la Presse Medicale, his last published article.
In publishing these examples of this great Frenchman's work we are, I believe,
doing a special service by making available something of the special contribution which
the French school makes to neurology. For many of us this has a different approach
which helps us to look afresh at the clinical and theoretical problems of child neurology.
Doctor Autgaerden, a devoted colleague of Andre Thomas for twenty years,
has worked unstintingly in the preparation of their book for us. We are indeed grateful
to her.
R. C. Mac Keith
Introduction
Some of the reactions of the infant during his first days of life, as compared with
those which arise later, give an impression of a greater briskness, approaching that of
reflexes. With the simultaneous anatomical and physiological development of nerve
centres, with their penetration by multiple nervous impulses, with the appearance of
Bechterew's associative reflexes and Pavlov's conditioned reflexes, a new motility
emerges whose manifestations, more eloquently than any theorizing, foretell the
intuitions and adaptive responses of the human being, and the strengths and weakness
es of the mind.
The movements of the newborn infant are, to a large extent, a continuation of those
of intra-uterine life. The new elements are merely the realisation of existing aptitudes
which needed an appropriate environment in which to develop.
Primary walking, for instance, which can be elicited from the very first day of life,
has been prepared for by the alternating movements of the legs in the foetus. To elicit
walking the newborn baby is held and supported in a suitable position in an optimal
environment, so that he can easily adapt to his new situation, and — even so, primary
walking does not necessarily occur at the first attempt. There is no infallible rule and
results vary from one moment to the next, but the possibility always exists.
Unlike the insect, whose instinctive behaviour is remarkably constant in its develop
ment and who fails to respond usefully to the unforeseen, the newborn has many
surprises for us in this respect. He is at once a curious and capricious creature. His
motor, or better his sensori-motor repertoire, develops continually under the triple
influence of the adaptability of the nerve centres, the multiple afferent impulses which
reach them and, especially, the impulses related to vegetative function. In the course
of this evolution intimate links are formed between the child's internal life and his
relation to the environment.
At this point another essential factor intervenes: the 'affect,' which, as the reception
of afferent impulses develops into sensations, will gradually advance to 'affectivity'
(the association of sensation with personalities such as the child's mother, the linking
of any activity with its social context. Ed.)
From the moment of conception, heredity, too, is exercising its influence; we may
be alike but we are not identical, even in a large family with the same parents.
The smallest details are important in the study of the young child. Simple observa
tion of the child's spontaneous behaviour is instructive, but if one is to get any clear
idea of his physiological state it is necessary to make a methodical examination. This
will naturally vary according to the child's age.
This sort of study can only be properly conducted in a hospital environment to
which the observer is accustomed and where unlimited facilities for further investiga
tion are available. We are indebted to Professor Levy-Solal and his successor, Professor
Lacomme, of the Clinique Baudelocque, for allowing us to work in their wards.
Similarly we remember with affection and gratitude the mornings we spent in the Out
patient Department at Valencourt where we were received so warmly by Mademoiselle
Lautmann. We would also like to thank the midwives, matrons and nurses who, by
their devotion and collaboration, made our work so much easier.
Preamble
Despite all the progress in anatomical and physiological studies, it is still difficult
to know just when, at what moment in development or growth (taken in its widest
sense), what we call the mind manifests itself; to know when, in what conditions and
in which modes of activity, it first takes charge. In the whole hierarchy of the nervous
centres, is it possible to indicate, in regard to any particular manifestation of motility,
at what stage any one of the spinal and cerebral centres came into play? Can one, for
instance, pinpoint the time at which the rhombocephalon (pons), the myelencephalon
(bulb), the brainstem, the mesencephalon (midbrain), the cerebral hemispheres, the
basal ganglia and the cerebral cortex begin to function?
To compare monsters whose encephalon is reduced to the hind brain and the
medulla (pons and bulb) with the normal newborn may appear strange, but in examin
ing pontine anencephalics we elicit reactions which differ only in intensity from those
observed regularly in the newborn. Some anencephalics suck and swallow normally,
react normally when sugar or salt is placed on their tongue, with an expression similar
to that of the normal newborn undergoing the same test. From this one must not
infer that the origin of the newborn's motility is exclusively pontine, and in any event
there are differences from one anencephalic to the next in the righting phenomena
which only occur in particular conditions.
Although the pons and bulb exist in the pontine anencephalic, they are not quite
normal. It may be thought excessive to dwell on this, but even the great physiologist
Vulpian regarded the protuberance (pons) as the centre of 'sensorium commune' and
locomotion. His conclusions were based on the results of experiments upon animals,
experiments which consisted in cutting above the pons or the bulb and comparing the
physiological consequences at various levels of the cutting. In the human it is
not possible to compare observations with experimental results, and yet we were very
surprised to hear a few hours' old anencephalic babble musically, and modulate quite a
long phrase. As another stirred on two occasions his arms rose while he gave forth a
hissing noise with the lips, just as, in the pontine rat observed by Vulpian, the cry
was more prolonged and grew stronger than that of the bulbar rat.
Frequently pontine anencephalics suffer convulsions, either spontaneous or
caused by the lightest touch on the pseudo-encephalon, the pouch which replaces
the brain. This stimulus is transmitted by the trigeminal nerve to the pons and thence,
by way of the substantia reticula, to the spinal centres. The convulsions are tonic in
some and clonico-tonic, or even tremulous, in others, but in the case of the latter
it is probable that the impressions caused by peripheral discharge excite reflex activity
of the spinal cord. In the tonic flexor convulsion, the anencephalic is capable of adopt
ing the sitting position by himself and then returning to the supine posture.
We emphasize these considerations because such phenomena are surprising
on account of the problems they raise. Responses which are found both in the normal
newborn and in the anencephalic are intriguing and it is embarrassingly difficult to
imagine the nervous mechanisms which are involved and their localisation in the
nervous centres.
The task becomes easier in the normal infant when refined sensory discrimination
becomes evident, when thought expresses itself in language, and when what is at first
new and requires initiative later becomes automatic.
But surely the highest nerve centres begin to function long before the obvious
intellectual period, well before pure reflection? Thought must surely be present in a
number of motor activities which are neither reflexes nor reactions and which seem
to imply the activity of cortical centres, when gestures and facial expressions are already
significant. Can one distinguish motor processes and psychomotor processes before
purely mental activities manifest themselves, before thought expresses itself in words?
Such a problem can only be tackled by referring to the examinations which are
conducted at the beginning of life, which most people take to mean at birth. But birth
is not the beginning of life. Life starts at the moment of fertilisation. The human
being lives and develops in the uterus and it is there that the first movements take place.
It is there also that aptitudes are elaborated which will appear later as conditions
favour their realisation, conditions which depend both upon the anatomico-physio-
logical development of the nervous system and upon the external environment in which
growth takes place. Aptitudes which are more or less slow to be realised contain a
considerable number of possibilities, some general, others individual, and all genetic
or hereditary in origin.
CHAPTER 1
Methods of Investigation
In our neurological studies of the newborn and the baby we have always used the
same methods.* However, with the experience of studying a larger number of children,
new facts have been established and some modifications in our technique have been
introduced. Analysis of movement suggests a finding which can lead to a close discus
sion of interpretation.
Motor activity in the newborn is, to a great extent, a continuation of the movement
of the foetus. Life starts with impregnation, and after four months the foetus executes
movements which are felt by the mother; embryologists have elicited reflex movements
from aborted foetuses of three to four months, such as contractions of the lip muscles,
and of the tongue through perioral stimulation. A little later movements of the arms
can be elicited by passive displacement of the head and neck (Minkowski 1955).
Conducting an internal version to facilitate delivery, the accoucheur's finger may
be seized by the lips of the foetus. The amniotic fluid penetrates the bronchial tree,
the oesophagus and the digestive tube as far as the intestine; it is resorbed at the level
of the ileum, enters the blood-stream and is finally brought by the umbilical vessels and
placenta to the mother's blood-stream. At birth a pharyngeal reflex appears which
henceforth prevents the penetration of liquid into the respiratory passage — a
wonderful example of integration which, together with oxygenation of the blood by
the mechanical action of the respiratory muscles and crying, represents a triad of
integrations of new functions.
Newborn infants put their fingers to their mouths almost immediately. Sometimes
they have been seen with the fingers of one or both hands on the lower lips during the
moments immediately following delivery. During examination, before the ingestion of
any liquid, even before the traditional spoon of sugared water, the newborn makes
rhythmic sucking movements. There are some who suck their thumb or index finger
during their first twenty-four hours of life.
If the observer places his finger on the lips or pushes it deeper between the gums,
it is sucked by the lips and the jaw drops and lifts rhythmically. This is also the re
sponse of the newborn of seven months' gestational age or a little more. There is
every reason to believe that, given the position of the foetus in the uterus, its fingers are
never very far from its mouth, and in the course of displacements caused by movements
of the mother or the foetus's own reflex movements, the fingers and lips must come
into contact more than once. It is clear, therefore, that sucking and even swallowing
begin in intra-uterine life. As we have indicated elsewhere, an undamaged brain is not
essential for sucking and swallowing movements, since these can easily be elicited by
For full list of publications by these authors, see Bibliography.
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lightly stimulating the lower lips of the anencephalic. If salt is placed on the tongue of
the anencephalic it grimaces and the tongue pushes forward as though to rid itself of
the disagreeable stimulant. On the other hand, when sugar is placed on the lips, the
anencephalic licks them. We have never seen one with its fingers on its lips, nor have we
been able to make one walk. It is true, however, that its life is usually very short and
those we have observed have not lived beyond two to four or five days.
Not all neonatal activity begins in intra-uterine life, where almost all movements
are reflex ones of some sort. They are tactile and to a large extent autotactile in origin,
the reflexogenic impressions coming from contact of the body with the uterine walls or
even from different parts of the foetus's own body knocking against one another.
These tactile sensations, of course, continue after birth, but their origin is different
— the impressions come from a different environment, from objects and from living
creatures. When he is first picked up the child reacts violently to the shock of bodily
impressions, but he quickly becomes accustomed to them and, unless there is excessive
heat or cold, is no longer agitated when handled.
The baby is born with a well-defined motility but also with aptitudes which will be
fulfilled in the course of his anatomical and physiological development, with the
growth of his body, and also under the influence of the external environment, his
genetical make-up, and his heredity and personality.
A mode of activity which does not date from intra-uterine life, but which is to
quite a large extent prepared by it, is automatic walking. Left to himself the newborn
child is not able to walk or to stand, but he will not be any more able to do so when,
between the ages of 9-15 months, supported and accompanied he makes his first step.
If the infant is lifted up a few minutes after birth and held with his feet touching
the ground, he will straighten up; if he is pushed slightly and bent forward, he will
make his first steps; they will sometimes lack timing, but a few hours later he will be
more regular and rhythmical. He can be made to stand, sometimes on one foot alone.
His supporting activity, the movements of the legs from flexion to extension and
extension of the trunk on his legs are easy, and apparently spontaneous. Once the
first steps have been taken, the automatic walking continues regularly, rhythmically
and accurately, with the body straight and the head itself held upright and steady.
All the observer has to do is to hold the body between the thumb and the index
finger of each hand under the armpits, in line with the axis to prevent the trunk from
rocking from side to side. Backward-forward rocking does not occur so readily.
The support thus given to the baby is not great and he can almost be said to
straighten himself and walk on his own account; the pressure of his feet on the ground
and the reaction of the extensor muscles to being stretched seem to be the most im
portant factors, coupled with the weight of the body increasing the flexion of the
limbs and trunk, followed by the stretching of the antagonist extensors. A stretch
reflex occurs.
Nevertheless, the newborn is capricious and does not always walk to order.
Well disposed one moment, he is no longer so the next. The examiner is discouraged
and gives up; then he changes his mind and tries a last time — the baby starts walking
2
immediately, perfectly regularly and over a long distance. Even though attempts to
elicit primary walking fail repeatedly, the possibility is still there. At ten o'clock he
may not walk, but a few seconds later he may.
Can we do anything to obtain more consistently successful results between birth
and the day when walking becomes impossible ?
Certainly the manner in which the baby is held is of importance. If one lightens
the weight of the body by holding the baby with both hands level with the lumbar-
sacral joint one succeeds more easily than if the baby is held under the armpits with the
thumb and index finger alone. But neither is this method infallible, especially when the
child reaches the stage when he puts his toe and not his heel on the ground first. It
seems to have been established that the presentation of the heel results largely from
the dorsiflexed position of the foot at birth. Passively flexed and extended the foot
now moves much further in extension than flexion, in which it scarcely exceeds a right
angle. There is thus a change in the passive — so-called resting — muscular tonus and
in the active tonus.
At this stage of development, no matter how the infant is held, it has been observed
that if one foot is made to touch the ground as though to start walking, alternating
movement of the lower limbs may start immediately. Other factors may now play a
part — sight, for example, which, in fact, does intervene, and has an important role
because the images involved are those with symbolic and emotional significance.
When, as a last resort, having failed to elicit walking, the examiner asks the mother
to stand in front of the baby, one of three things may happen: the baby leans his body
towards his mother (with flexion of the legs at the ankle-joints), or he springs off on
one foot in her direction, or he suddenly starts to walk — this walking is not as rhyth
mical and regular as it has been before. The examiner may also elicit walking by
encircling the baby with his arm, pressing his feet hard against the ground and pulling
him forward, but this is no longer true primary walking for the baby is strongly
guided and supported.
Be that as it may, there is a period during which the baby walks less willingly
and the foot assumes a different position. Even children who have been trained
daily in walking exercises go through such a period when they stand on the tips of
their feet but are slow to advance. Sometimes it is possible to elicit walking with
children beyond this period by resorting to such subterfuges as the sight of the mother,
the sound of her voice calling and her arms held out — all of these emotional stimuli
succeed where others fail.
Walking Upwards on an Inclined Plane
We have been astonished in the course of these studies by the great ease with
which one can make the baby walk in certain conditions. Standing with the top part
of his body inclined backwards, the observer holds the baby by the trunk, with his
hands, and lets the baby's feet touch the front part of his own body — not only does
the baby stand up, he also climbs up. The baby is relieved of most of the weight of
his body and his straightening response is facilitated. The test frequently succeeds
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