Essays In Pastoral Medicine Part 7

Doctors are very familiar with this tendency to make up stories to account for various deformities. It used to be considered that hip-joint disease and Pott's disease were the result of injuries in early life. They are now known to be due to tuberculous processes not necessarily and indeed only very seldom connected with injuries of any kind. Mothers are {63} nearly always able to account in some way, however, for the beginnings of the disease in some accident that has happened. Young children are apt to have so many falls that some one of them is picked out as the probable cause of the disease that subsequently manifests itself in the joints. It is just this state of affairs that occurs with regard to supposed maternal impression. Some incident that would be otherwise unthought of is magnified into an accident that caused a serious nervous shock, and consequently led to the marking of the child.

In general it may be said for the clergyman's direction, that if women have, as is sometimes the case, a morbid sense of their guiltiness with regard to some maternal impression that has set a mark upon their child, such a state of feeling may very well be rendered less poignant by a frank statement of the present att.i.tude of mind of most physicians with regard to the possible effects of maternal impressions. Scepticism is much more the rule than it used to be, and as time goes on fewer and fewer of the cases that used to be considered so inexplicable in the direct relationship that seemed to exist between maternal impression and deformity in the child are reported. Fifty years ago nearly all the authorities on this subject were agreed in considering that maternal impressions did play some part, though they could not explain just how, in the production of certain deformities. Now we venture to say that most of the thinking physicians who have occupied themselves with this subject would scarcely hesitate to say that they were utterly incredulous of any such effects being produced. The lack of any direct nervous or blood connection between mother and child is the basis for such disbelief, and is of itself the best argument against the old tradition.

With regard to mental defects, as a rule, not so much is said as for bodily defects. Bodily deformities are noted at once after birth, and then the mother recalls some incident of the pregnancy to account for them. Mental defects are, however, noticed much later, and are not so likely to be considered as connected with incidents of the puerperal period. There is no doubt that if the mother has had to pa.s.s through a series of emotional strains, or has suffered from severe {64} shocks, children are likely to be born with diminished mental capacity. This is, however, not difficult to understand, since such incidents produce disturbances of the nervous system of the mother, and consequently also of her nutrition, and this is p.r.o.ne to be reflected in the child's condition, especially in that most delicate part of the child's organism, the brain. Hence it is that children born during the siege of Paris, or shortly after, were defective to such a marked degree that they were spoken of as "children of the siege," and this was considered to be quite sufficient explanation of nervous peculiarities later in life.

Baron Larrey, the distinguished French surgeon, made a report with regard to the children born after the siege of Landau in 1793. Of 92 children, 16 died at birth, 33 died within ten months, 8 showed marked signs of mental defects, most of them to the extent of idiocy, and two were born with several broken bones. In this case, however, it is well known that besides the shock of the danger consequent to the siege and the fear and distress of the women with regard to their husbands and relatives, there were added many privations and physical sufferings.

The nutrition of the mothers was seriously disturbed by these, and it might well be expected that the children should suffer severely. The statistics of such events are not available in general, and when an effort is made to establish a cause for idiocy under other circ.u.mstances, none is usually found. Out of nearly five hundred cases of idiots whose histories were carefully traced in Scotland, in only six was there any question of maternal impressions having been the cause of the condition.

Of course there are many very wonderful coincidences that seem to confirm the idea that impressions made upon the mother's mind are sometimes communicated to the child in her womb. That they are not more than coincidences, however, is rather easy to demonstrate in most cases, since, as a matter of fact, at the time when the incident occurred which is supposed to have caused the deformity in the foetus, the stage of development of the intrauterine child has pa.s.sed long beyond the period when formative defects could occur. For instance, it sometimes happens that the child-bearing woman {65} sees an accident especially to the father of the child involving the loss of a limb.

If, by chance the child should be born with a missing member, as sometimes happens, then there would seem almost to be no doubt of a direct connection between the accident witnessed, the effect produced upon the mother's mind, and the consequent deformity.

We know now that the formation of the limbs of the foetus is complete by the end of the third month. At this time the woman is scarcely more than conscious of the fact that she is pregnant, and it is not during this early period, as a rule, but during a much later period, that maternal impressions are supposed to have their influence. It is only such maternal impressions as occur very early in pregnancy, before the tenth week as a rule, that could possibly have any effect in the production of such deformities. It is by no means infrequent, however, to have children born lacking one or both limbs. Sometimes nothing but the stumps of limbs remain. In such cases it is now well known that intrauterine amputation has taken place. Some of the membranes that surround the child, especially the amnion, become separated into bands which surround tightly the growing members of the foetus and by shutting off the blood supply through constant pressure, lead to the dropping off of all that portion of the member lying below the band.

Not infrequently it happens that when a child is born thus deformed, the mother, by carefully searching her memory, can find some dreadful story that she has read, some accident that she has seen or heard of, and that has produced a seriously depressing effect upon her at the time, to which she now attributes the deformity that has occurred.

Until the unfortunate appearance of her child was reported to her, she had no idea of any possible connection between the story and the bodily state of her intrauterine child. In not a few cases, however, the most faithful searching of the memory fails to show anything which could, by any possible connection, be made accountable for the deformity; and these cases, we may say at once, are in a majority.

Not a little of a popular notion with regard to the influence of maternal impression is due to the repet.i.tion of certain {66} village gossip which by no means loses its point or effectiveness pa.s.sing from mouth to mouth. On the other hand, maternal impressions have been exploited by novelists, who have found that the morbid curiosity of women particularly with regard to this subject may make their stories more widely read. Lucas Malet, who, in spite of the apparently masculine pseudonym, is really the late Rev. Charles Kingsley's daughter, has recently called renewed attention to this subject by her novel "Sir Richard Calmady." In this the hero is born with both his lower limbs missing from just below the knees. The author has been careful, however, with regard to the details of the supposed maternal impression to which this deformity is attributed. A young married woman in the early part of her first pregnancy has her husband, whom she loves very dearly, brought back to her with both his limbs taken off by a shocking accident which resulted fatally. It is not impossible, some physicians might think, to consider that so severe a shock could produce a very deleterious effect upon the foetus. That the result should so exactly copy the scene which was brought under the eyes of the young mother is, however, beyond credence.

Occasionally such stories, supposedly on medical authority, find their way into the newspapers, usually from distant parts of the country.

Certain parts of Texas particularly seem to be a fruitful source of such stories for newspaper correspondents when there is a dearth of other news. Farmers in thinly settled parts of the country lose a foot in a reaping machine or a hand in the hay-cutting machine when there is no one near to help them but their wives, with the result that the shock to their wives proves the occasion of a similar deformity in an as yet unborn child. Careful investigation of such cases, however, has invariably shown that either they were completely false or that the details showed that whatever had happened was at most a coincidence and never a direct causative factor in the subsequent deformity.

The greatest difficulty in the mind of the medical man, with regard to the possibility of maternal impression being communicated in any way to the foetus, is, as we have said, his knowledge of the anatomy of mother and foetus. While it is {67} generally supposed that the mother is very intimately connected with her child _in utero,_ the actual connection is by no means so direct as might be expected from the popular impression. It is usually considered that the mother's blood flows in the child's veins; but this is absolutely false. The child's blood is formed independently of the mother's blood quite as is that of the chick in the egg. At all times the blood of the child remains quite different in const.i.tution to that of its mother. It contains many more red cells than does her blood and differs in other very easily recognisable ways. Mother and child are connected by means of an organ known as the placenta, which is attached very closely to the uterine wall and from which through the cord the blood of the foetus circulates. This placenta const.i.tutes the so-called afterbirth. The mother's blood flows in one portion of it, that of the child in another, and they always remain distinct and separate from each other.

The gases necessary for the child's life diffuse through the membrane which separates the two different bloods, and the salts and soluble proteids necessary for the child's nutrition, as well as the water necessary for its vital processes, all pa.s.s through this membrane, but at no time is there any direct blood connection between mother and child. Indeed, for a large part of the formative period of the foetus life, that is, during the first two months of its existence, the ovum is not very closely attached to the uterus at all, but grows by means of the vital power which it has within itself.

Nor is there any direct nervous connection between mother and child; indeed, there are no nerves at all in the placenta, and none in the cord through which all communications between mother and child must pa.s.s. It seems impossible to explain, then, how maternal impressions can so effectively pa.s.s from mother to child; and indeed, the whole subject, when looked at in this way, is apt to be considered legendary, and the facts adduced in support of the theory of maternal impressions are practically sure to be thought mere coincidences. A little knowledge here might seem to justify many things that more complete knowledge fails to be able to find any reasons for.

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There is no doubt, however, that the mother's environment during pregnancy is in general very important for the perfect development of the intrauterine child. Many more deformed births are reported after times of stress and trial, as, for example, after the sieges of great cities, notably the siege of Paris in 1871, and such scenes of desolation as occurred during the thirty years' war in Germany. These are, however, not direct, but indirect effects of maternal impressions. The development of the human being _in utero_ is an extremely complicated process. Any disturbance of it, however slight, is sure to be followed by serious consequences. Disturbances of nutrition, such as are consequent upon the deprivation that has to be endured in times of war or during sieges, is of itself sufficient seriously to disturb even the uterine life of the child. In these cases, however, there will be no traceable connection between the form of the maternal impression and the type of deformity that occurs. This is, however, the essence of the old theory of the direct effect of maternal impressions, and consequently that theory must fall to the ground.

From all that has been said, however, it becomes very clear that as far as possible women should be shielded from the effect of various nervous shocks during their pregnancy, and that they owe it to themselves and their offspring to be careful with regard to any morbid manifestations of feeling that they may detect in themselves.

JAMES J. WALSH.

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VI

HUMAN TERATA AND THE SACRAMENTS

Teratology ([Greek text], a monster) is a part of biology that treats of deviation from a normal development in man and the lower animals.

The name was adopted in 1822 by the elder Saint-Hilaire, who then attempted to separate the results of modern exact methods of research from the myths and loose descriptions of monsters found in the writings of old authors. Cicero (_De Divinatione_) derives the term monster from the proper preternatural signification looked for in the occurrence of these abnormal beings: "Monstra, ostenta, portenta, prodigia appellantur, quoniam monstrant, ostendunt, portendunt et predic.u.n.t."

At the end of the seventeenth century Malpighi and Grew discovered that plant tissue is entirely made up of microscopic s.p.a.ces enclosing fluid; they called these s.p.a.ces _cells_. Different investigators found that animal tissue is also composed of cells; and between 1835 and 1839 Schwann and Schleiden formulated the law that every metazoic organism is made of cells, and starts from a cell.

In 1672 de Graaf discovered the mammalian ovum, in 1675 Ludwig Ham found spermatozoa, in 1827 von Baer recognised the human ovum, but not until 1875 was the important fact established that fertilisation is effected by the fusion of the male and female p.r.o.nuclei. This was demonstrated by Oscar Hertwig from observation of the ova of starfishes.

Mammalian ova, owing to an almost complete lack of yolk, are all small. The egg of a whale is about the size of a fern-seed, but the yolked eggs of birds are large--that of the great auk was 7.5 inches long. In man the ovum is from 0.18 to 0.2 mm. in diameter, scarcely visible to the {70} naked eye, and the spermatozoon is extremely minute. The human spermatozoon is only fifty-four thousandths of a millimetre in length, and from forty-one to fifty-three thousandths of a millimetre are taken up by its flagellum. The essential part is from four to six thousandths of a millimetre in length (Dr. L. N. Boston, _Journ, of Applied Microscopy_, vol. iv. p. 1360). A line of 18 human spermatozoa would reach only across the head of an ordinary pin. These spermatozoa have the power of locomotion in alkaline fluid. Henle found they can travel one centimetre in three minutes.

The human ovum and spermatozoon are single cells, and the princ.i.p.al parts of a typical cell are the cytoplasm (called also the protoplasm), and, within this, the nucleus and centrosome. The centrosome is efficient in the process of cell-division. A few cells have also an outer envelope or membrane, and this part is well developed in the ovum.

The nucleus is the centre of activity in a cell. In the resting state it is surrounded by a membrane, and within the membrane is an intra-nuclear network made up of chromatin and linin--the chromatin is an important element. The meshes of this network are probably filled with fluid.

During the stages preparatory to the mitotic, or indirect, division of a cell into two cells (one of the methods of reproduction) the chromatin segregates in typical cases into two groups of loops, and each group has equal portions of the chromatin. When the chromatin is in this shape, a loop is called a chromosome.

The chromosomes are very important. They occur in constant definite numbers in the somatic cells of the various species of many animals and plants, and it is probable that each species of plant and animal has its own characteristic number of chromosomes. Wilson (_The Cell in Development and Inheritance,_ New York, 1890) gives a list of 72 species in which the number has been determined. Man has probably 16 chromosomes in the somatic cell, and the mature male and female germ cells in man contribute eight chromosomes each to the nucleus of the impregnated ovum.

The chromosomes transmit the physical bases of heredity from one generation to the next, and the heritages from the two parents are equal except in cases of prepotency. Every cell {71} in the human body is derived from the father and the mother equally. The fact that the woman carries a child for months in her womb means only that she employs a peculiar method of feeding and protecting it. After its birth she feeds it from her b.r.e.a.s.t.s, before birth through its umbilical vessels, but she originally gives only the eight chromosomes as the father does, and the child's vital principle builds up the body from this foundation. The popular notion that the foetus in the womb is formed through some process of literal abstraction from the maternal tissues is no more true than that the infant is so built up while it is suckling; both processes are merely different methods of feeding.

All the chromosomes from the fathers of at least 200 men could fit simultaneously on the head of one pin, yet virtually, not merely potentially, half the bodily substance of that mult.i.tude, and all the physical characteristics derived from the 200 fathers, are indubitably contained in those chromosomes and nowhere else, unless by a special creation they are infused with the new soul, which seems to be an altogether unreasonable alternative. This statement concerning the minuteness of the chromosomes is not speculation--they can readily be seen and measured with the aid of the microscope.

A human being, then, obtains eight microscopic chromosomes from his father and eight from his mother, positively nothing more except food; yet he develops into a man with a body made up of countless millions of cells which expand into more than 200 bones in the skeleton and over 200 muscles,--into the fascias, ligaments, tendons, the great and small glands, the lymph and blood systems, the respiratory and alimentary tracts, the skin and its appendages, and a nervous system, which alone furnishes material for years of study if we would learn its anatomy fully. Not only all this, but the man commonly closely resembles his father or his mother, or some other ancestor, in personal appearance, in certain physical tendencies, in graces or blemishes; and furthermore, he shows inherited racial characteristics.

If a father is prepotent, he may have a greater effect in producing the formed child than the mother has, and _vice versa,_ as when a son closely resembles his father or his mother. {72} Prepotency, moreover, may extend down through generations and centuries. In the streets of Palermo to-day typical Normans may be seen, despite the intermarriages of centuries, who are the descendants of those male Normans that went down to Sicily with Tancred. There are Romans there, too, and Saracens. When the Belgae--a race of tall, red-bearded men, with elliptical skulls--went from the continent of Europe to Ireland, probably six centuries before our era, they conquered the aborigines, a gentle, brune race of lower stature. These Belgae became the ancestors of the chieftain cla.s.s, and their physical type persists until to-day; so does that of the Pictish aborigines. Daniel O'Connell had a typical Belgic body. Other big, blond Irishmen are Norse or Danish in remote origin.

How is the extremely complex human body with its various physical characteristics built up from the nucleus of a fecundated cell, the ovum? The endeavour to answer this question has brought out most ingenious speculation from nearly all the great biologists of modern times. The question is the foundation of the theories of heredity, and it is also fundamental in the theories of evolution.

The human ovum is a flattened spherical cell, made up of a very delicate cell-wall, called the vitelline membrane; outside this is a comparatively thick membrane, the zona pellucida, which is properly not a part of the cell. Within the vitelline membrane is a granular cytoplasm, the vitellus (yolk), and in this lies the nucleus, which in the old text-books was called the germinal vesicle. This nucleus contains a nucleolus.

The human spermatozoon consists of a flattened head which has a thin protoplasmic cap extending down two-thirds of its length. In the head is the nucleus with the chromatin. Beyond the head is the neck, which contains the anterior and posterior centrosomes. Behind the neck is the tail, or flagellum, in three parts,--the middle piece, the princ.i.p.al part, and the end piece. From the neck to the end of the tail centrally runs a bundle of fibrils, the axial filament. In the middle piece these fibrils are wrapped within a single spiral filament which winds from the neck down to the annulus at the beginning of the princ.i.p.al part, and lies in a clear fluid. Without the spiral filament, along the middle piece, is the mitochondria, a finely granular protoplasmic layer. The princ.i.p.al part of the tail consists of the axial {73} filament enclosed in an involucrum, and the end piece is made up of this filament without the involucrum.

The head and neck of the spermatozoon, which contain the nucleus and centrosomes, are the essential parts, and the middle piece and the remainder of the tail appear to be used solely for locomotion and penetration. When the head penetrates the ovum, the tail is detached and rejected.

Our knowledge of the initial stages in the development of a human embryo is derived indirectly from the observation of other mammals.

There are nine early human embryos reported, and the average probable age of these is twelve days. Breuss' specimen was probably ten days old (_Wiener med. Wochenblatt,_ 1877). Peters (_Einbettung des mensch. Eies,_ 1899) found a smaller embryo than this. The Breuss ovum was 5 mm. in length; Peters' was 3 by 1.5 by 1.5 mm., but the probable age was not given. There have been numerous embryos more than twelve days old observed, and since the process after the twelfth day is identical in man and the higher mammals, there is no doubt that the first stages are also the same.

The segmentation that makes new cells is complicated, and the outcome of the division is a ball of cells. In eggs which have a large yolk, like those of birds, the cells form a round body resting on the surface of the yolk, but in mammalian ova a hollow ball of cells, or a _Morula,_ results, which lines the internal surface of the cellular envelope. The ovum absorbs moisture by osmosis and enlarges, and about the twelfth day after the germ-nuclei have begun to divide, the Morula, or hollow ball of cells, called also the _Blastodermic Vesicle,_ is formed.

The next stage in development is the establishment of two primary germinal layers, called together the _Gastrula_, The outer layer is the _Ectoderm_ or the _Epiblast,_ and the inner layer is the _Endoderm_ or _Hypoblast_. In a Morula the smaller cells, which contain less yolk-material, gradually grow around the larger yolk-containing cells to form the Gastrula.

Between the Ectoderm and the Endoderm a layer of cells called the _Mesoderm_ or _Mesoblast_ is next formed, and from these three layers all the parts of the embryo are built up. From the outer Ectoderm and the inner Endoderm those organs arise which are in the body, outer and inner,--as the nervous system and the outer skin from the Ectoderm, the inner entrails, the lungs and liver, from the Endoderm.

From the Mesoderm come the inner skin, the bones and muscles.

By this time the embryo is a minute longitudinal streak at the {74} surface of one pole of the ovum. The "Primitive Trace" is like a long inverted letter U, the legs of which are in apposition. The Primitive Trace becomes a circular flattened disc; and it grows into a cylindrical body by the juncture of the free margins which fold downward and inward and meet in the median line, and this closes in the pelvic, abdominal, thoracic, pharyngeal, and oral cavities. The legs and arms bud from this cylinder later. While the ventral cylinder is growing, another longitudinal cylinder is formed along the upper surface of the embryo, which will contain the brain and the spinal column. The subsequent development of the embryo and foetus need not be known for an understanding of the material considered in treating here of terata.

Human terata occur in certain rather definite, types of erroneous development, and the cla.s.sification of Hirst and Piersol (_Human Monstrosities_, Philadelphia, 1891), which is a combination and change of the cla.s.sifications of Geoffrey Saint-Hilaire, Klebs, and Forster, is the most satisfactory. There are four great groups of abnormally developed human beings: (1) Hemiteratic; (2) Heterotaxic; (3) Hermaphroditic; (4) Monstrous.

Hemiterata are giants, dwarfs, persons showing anomalies in shape, in colour, in closure of embryonic clefts, in absence or excess of digits, or having other defects. This group does not come under discussion here, but attention should be called to the fact that women who are dwarfs are to be warned before marriage that they cannot be delivered normally,--that the caesarean section or symphyseotomy will be necessary, or that certain physicians will practise craniotomy in delivering them.

The Heterotaxic group comprises persons whose left or right visceral organs are reversed in position through abnormal embryonic development; the liver is on the left side, the heart points to the right, and so on.

Of the next group, the Hermaphroditic, it may be said that a true hermaphrodite, in the full sense of the term, has not been found; but there have been several examples of individuals who had an ovary and a t.e.s.t.i.c.l.e, and other rudimentary s.e.xual organs that belonged to both male and female. Forms of apparent doubling are common, and in case of doubt as to s.e.x the probability leans toward the {75} masculine side.

As to marriage in such cases, questions may arise that are to be settled by the anatomist. In dealing with double monsters it is sometimes difficult or impossible to determine whether we have to do with one or two individuals, and this difficulty has serious weight, especially in the administration of baptism. It is improbable that there is a doubling of personality in hermaphrodites. A striking characteristic of compound terata is that the individuals are always of the same s.e.x; moreover, the embryonal development of reproductive organs in general is such as almost to preclude a question of duality of personality.

Terata, more properly so called, are divided into single, double, and triple monsters. Single monsters may be autositic, or independent of another embryo or foetus; or they may be omphalositic, that is, dependent upon another embryo or foetus, which is commonly well developed, and which supplies blood for both through the umbilical vessels. When an omphalosite exists, the other foetus is called, in this case also, the autosite.

The first order of autositic single monsters contains four genera with eight species, and under these species are thirty-four varieties. They may have imperfect limbs, no limbs, one eye in the middle of the forehead (_cyclops_), fused lower limbs (_siren_), and so on. Some of these monsters show a strong resemblance to lower animals, but there is no record that is in any degree scientific of a hybrid between a human being and a lower animal.

There are two genera of the omphalositic single monsters, with four species. One of the twins, the autosite, is commonly a normal child; the other, the omphalosite, may be as small as a child's fist, and be very much deformed. Of these omphalosites the _paracephalus_ has an imperfect head, commonly no heart, and the lungs are absent or rudimentary. The _acephalus_ has no head, and commonly no arms; the _asomata_ is a head more or less developed, with a sac below containing rudiments of the trunk organs. The Acephalus is very rare--the rarest of all monsters except the Tricephalus. There is a fourth kind--the _foetus anideus_. This is a shapeless ma.s.s of flesh covered with skin. There may be a {76} slight prominence with a tuft of hair on it at one end of the ma.s.s to indicate the head. In this monster there are more traces of bodily organs than might be expected.