Commentary: what might have been: Sullivan may have impacted modern prenatal alcohol research under different circumstances.

William Sullivan’s 1899 paper, ‘A Note on the Influence of Maternal Inebriety on the Offspring’, often cited as a precursor to modern fetal alcohol research, was published at a time when alcoholism was a topic of great interest in Europe and North America. Emerging theories of heredity, eugenics and temperance movements drove alcoholism research from 1860 to 1910. In addition to an upsurge of medical literature on alcoholism, a number of journals devoted to the topic were formed (e.g. Journal of Inebriety). Benedict Morel’s theory of hereditary degeneration was influential in the medical field generally, including research on alcohol and reproduction. This theory postulated that degenerative traits, of which alcoholism was thought to be one of the more obvious, pass on hereditarily and accumulate over generations, eventually leading to the extinction of the family bloodline by about the fourth generation. Since heredity was the transmitting mechanism for degenerative traits, paternal alcoholism was generally considered as detrimental as maternal alcoholism. While some researchers and activists were concerned that alcoholism would degenerate society as a whole, others suggested that through degeneracy and extinction of family lines the propensity for alcohol would limit itself. Since alcohol was readily available and its effects observable and treatable, the study of alcoholism as a degenerative condition was of particular interest, and most alcoholism research during this period supported the degeneration theory. Sullivan strongly advocated the theory of degeneration in his alcoholism research. As a physician serving in a Liverpool prison, Sullivan had access to life histories of alcoholic female inmates. His 1899 study involved two main components: an epidemiological study of female inebriates and their children, and a case study of 11 alcoholic mothers who were imprisoned while pregnant. Citing prior research summarizing the alcoholic tendencies of parents of ‘degenerates’, Sullivan’s aim was to distinguish alcoholism as the primary degenerative agent by investigating ‘not alcoholism in the ancestry of the degenerate, but degeneracy in the descendants of the alcoholic’. The research design constructed by Sullivan, the epidemiological data he collected and the analyses he conducted were quite impressive. Sullivan acknowledged limitations to the data while maintaining that results could be generalized to parental alcoholism. The validity of the study was enhanced by excluding inmates who were suspected of ‘other degenerative factors’, such as tuberculosis or syphilis, or who were ‘markedly neurotic’. When analysing outcomes of 600 children born to 120 alcoholic mothers, he found that the majority of children died before the age of 2 years. In addition, child mortality rates were higher among alcoholic mothers compared with sober female relatives. Perhaps, a more important aspect to Sullivan’s paper was a case study of 11 alcoholic mothers who were forced to abstain from alcohol during pregnancy because of imprisonment. Among these mothers, Sullivan found decreased mortality of children who were in utero during imprisonment relative to their siblings who were likely exposed to alcohol prenatally. Although Sullivan acknowledged that other environmental factors related to parental alcoholism could play a role in child mortality rates or negative outcomes, he suggested not only that the impact of maternal alcohol consumption was considerably greater than that of paternal alcohol consumption, but that alcohol appeared to have a ‘direct toxic action on the embryo’. A direct action of alcohol on the developing fetus proposed by Sullivan has been confirmed in modern day prenatal alcohol research. Increases in stillbirths and infant mortality have been confirmed among mothers who drink heavily or binge while pregnant. The impact of alcohol on the developing fetus extends beyond increased mortality, however, as research has confirmed a neurodevelopmental impact caused by heavy prenatal alcohol consumption. Although the neurocognitive profile continues to emerge, Published by Oxford University Press on behalf of the International Epidemiological Association