{48}
If pregnancy ends in the emptying of the uterus before the sixteenth week of gestation, the condition is called an abortion; if this happens between the sixteenth and the twenty-eighth weeks, it is miscarriage; if the child is born after the twenty-eighth week but before full term, the birth is premature. The term "abortion" in the popular mind carries with it the notion of criminal interference, and the word "miscarriage" is used for both abortion and miscarriage by the laity; physicians, on the other hand, commonly use the term "abortion" for both abortion and miscarriage. These conditions may occur spontaneously or they may be induced artificially.
Spontaneous abortions are very frequent; perhaps one in every five or six pregnancies is the proportion: the writer has known a single physician, not a specialist in obstetrics, to be called to three in one day and that in private practice. From 150 to 200 children in every 1000 that are conceived never get a chance for baptism. In the early months of pregnancy the foetus is usually dead before expulsion takes place. Twisting of the cord, hydramnios, syphilis, an acute infectious disease in the mother, poisonings of the mother by metals and the like substances, maternal cardiac and renal diseases, chronic inflammations and displacements of the womb, and violent emotions are some of the causes of abortion. In certain women a slight exertion, a misstep, a fall, a ride over a rough road, thedebitum conjugale, and similar causes bring on abortion; in other women almost no shock is enough to make them miscarry. Inflammations and displacements of{49}the womb cause most of the abortions in the first four months, and after that time syphilis and Bright's disease are the chief forces at work.
If a woman in early pregnancy begins to lose blood from the uterus, and has pain in her back and lower abdomen, abortion is threatened; if this hemorrhage is marked, and the cervix is dilated, the abortion will very probably occur; and the escape of theliquor amniirenders the abortion unavoidable. In this latter case the vagina and the cervical canal are packed with sterile gauze to check the hemorrhage, and after twenty-four hours it is removed. Then commonly the entire ovum comes away with the gauze, or what remains of it is taken out with a curette.
Valvular lesions of the heart in pregnancy make a maternal mortality of about 28 per centum, according to Guérard, and when compensation is lost the mortality may run from 48 to even 100 per centum with different physicians and different cases. The prognosis is good as long as compensation is retained, but very bad if this fails. In the latter condition premature labour is indicated, or the early removal of the viable child. Catholic physicians may not induce artificial abortion of an unviable foetus. The decree of the Holy Office concerning this matter is as follows:
Beatissime Pater,—Stephanus … Archiepiscopus Cameracensis … Quae sequuntur humiliter exponit:Titus medicus, cum ad praegnantem graviter decumbentem vocabatur, passim animadvertebat lethalis morbi causam aliam non subesse praeter ipsam praegnationem, hoc est, foetus in utero praesentia, una igitur, ut matrem a certa atque imminenti morte salvaret, praesto ipsi erat via, procurandi scilicet abortum seu foetus et ejectionem. Viam hanc consueto ipse inibat, adhibitis tamen mediis et operationibus, per se atque immediate non quidem ad id tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut vivus, si fieri posset, ad lucem ederetur, quamvis proxime moriturus, utpote qui immaturus omnino adhuc esset.Jamvero lectis quae die 19 Augusti, 1888, Sancta Sedes ad Cameracenses Archiepiscopos rescripsit:tuto doceri non posselicitam esse quamcumque operationem directe occisivam foetus, etiam si hoc necessarium foret ad matrem salvandam: dubiis haeret Titius circa{50}liceitatem operationum chirurgicarum, quibus non raro ipse abortum hucusque procurabat, ut praegnantes graviter aegrotantes salvaret.Quare ut conscientiae suae consulat supplex Titius petit: utrum enuntiatas operationes in repetitis dictis circumstantiis instaurare tuto possit.Feria iv, die 24 Julii, 1895.In Congregatione generali S. Romanae et Universalis Inquisitionis … Emi ac Rmi Domini Cardinales … respondendum decreverunt:Negative, juxta alias decreta, diei scilicet 28 Maii, 1884, et 19 Augusti, 1888.… Sanctissimus Dominus noster … approbavit.
Other documents referring to the same matter are the following:
Epistola ad Archiepiscopum Cameracensem. … Anno 1886, Amplitudinis tuae Praedecessor dubia nonnulla hinc supremae Congregationi proposuit circa liceitatem quarumdem operationum chirurgicarum craniotomiae affinium. Quibus sedulo perpensis, Eminentissimi ac Reverendissimi Patres Cardinales una mecum Inquisitores Generales, feria iv, die 14 currentis mensis, respondendum mandaverunt:In scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam craniotomiam appellant, sicut declaratum fuit die 28 Maii, 1884, et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis.Idque notum facio Amplitudini tuae, ut significes professoribus facultatis medicae Universitatis catholicae Insulensis. …Romae, die 19 Augusti, 1889. …R. CARD. MONACO.
The date of this response here is 1889, but in the preceding decree it is given as 1888. In theActa Sanctae Sedisthe date is 1889.
Another letter from Cardinal Monaco is this:
Eme et Rme Dne,—Emi PP. mecum Inquisitores generales in Congregatione habita feria iv, die 28 labentis Maii, ad examen revocarunt dubium ab Eminentia tua propositum—An tuto doceri possit in scholis catholicis licitam esse operationem chirurgicam, quam Craniotomiam appellant, quando scilicet, eâ omissâ, mater et infans perituri sint, eâ e contra admissâ, salvanda sit mater, infante pereunte?
{51}
—Ac omnibus diu et mature perpensis, habita quoque ratione eorum quae hac in re a peritis catholicis viris conscripta ac ab Eminentia tua hinc Congregationi transmissa sunt, respondendum esse duxerunt:Tuto doceri non posse.Quam responsionem cum SSmus D. N. in audientia ejusdem feriae ac diei plene confirmaverit, Eminentiae tuae communico. …R. CARD. MONACO.Romae, 31 Mail, 1884.Emo Archiepiscopo Lugdunensi.
Another decree concerning abortion is in part as follows:
Beatissime Pater,—Episcopus Sinaloen. ad pedes S.V. provolutus, humiliter petit resolutionem insequentium dubiorum:I. Eritne licita partus acceleratio quoties ex mulieris arctitudine impossibilis evaderet foetus egressio suo naturali tempore?II. Et si mulieris arctitudo talis sit, ut neque partus praematurus possibilis censeatur, licibitne abortum provocare aut caesaream suo tempore perficere operationem? …Feria iv, die 4 Mail, 1898.In Congregatione habita, etc. … EE. ac RR. Patres rescribendum censuerunt:Ad I. Partus accelerationem per se illicitam non esse, dummodo perficiatur justis de causis et eo tempore ac modis, quibus ex ordinariis contingentibus matris et foetus vitae consulatur.Ad II. Quoad primam partem,negative, juxta decretum Feria iv, 24 Julii, 1895, de abortus illiceitate. Ad secundum vero quod spectat; nihil obstare quominus mulier de qua agitur caesareae operationi suo tempore subjiciatur. …In sequenti Feria vi, die 6 ejusdem mensis et anni … SSmus responsiones EE. ac RR. Patrum approbavit.
Pyelonephritis (an inflammation of the kidney where pus is present), from the pressure of the pregnant uterus, is a condition which sometimes obliges the physician to bring about premature labour to save the mother. The symptoms usually appear in the latter half of gestation.
Chorea ("St. Vitus' Dance"), when it develops during pregnancy, has a maternal mortality of from 17 to 22 per centum. It may cause death before the child is viable, and to empty{52}the uterus will stop the symptoms. Here the decrees of the Holy Office will occasionally prevent the Catholic physician from interfering.
If a grave surgical operation is imperatively indicated during pregnancy, and may not be put off until after delivery, it should be undertaken in many cases, because modern technique commonly does not bring about an abortion; but, in general, no rule can be given—each case must be judged separately.
If a pregnant woman has at the same time considerable albumen in her urine and a low excretion of urea, her condition is very dangerous. To empty her uterus will, in most cases, relieve the renal trouble, but in any case premature labour is not to be induced rashly: many women escape, when by all the rules they should die.
Eclampsia is a very grave complication of pregnancy, and it was formerly supposed to be uraemia. The disease is characterized by convulsions, loss of consciousness, and coma. It occurs, commonly, in the second half of gestation, but it has been observed as early as the third month. About 70 to 80 per centum of the cases are in primiparous women. The convulsions may come on altogether unexpectedly, but commonly the attack begins with symptoms of toxaemia. Eclampsia may occur before, during, or after parturition. When it comes before term it usually ends in spontaneous or artificial abortion, but at times the woman dies undelivered. Now and then she may recover and be delivered at term.
The kidneys are usually affected, even in those cases in which albuminous urine is not found. There is also a hemorrhagic inflammation of the liver; and oedema and congestion of the brain, with or without apoplexy, are other symptoms of the disease. There are other lesions, but the chief are in the kidneys, liver, and brain.
The aetiology of the disease is not yet known, and there are very many theories offered to explain it. The prognosis is always serious, and the condition is one of the most dangerous found in pregnancy. The mortality varies, but it is about from 20 to 25 per centum in the women, and from 33 to 50 per centum in the children. It is impossible to determine{53}the prognosis in particular cases, but a large number of quickly recurring convulsive seizures, with a weak, thready pulse, and a high temperature usually indicate a fatal ending. Apoplexy, oedema of the lungs, and paralysis also, as a rule, end in death.
If the uterus is emptied during the convulsions, these cease either immediately or soon after delivery, in from 66 to 93 per centum of the cases, and the maternal mortality then is about 11 per centum. With the expectant treatment, in convulsive cases, about 28 per centum of the women die, although a use of aconite in these cases may better the prognosis.
Pernicious vomiting (hyperemesis gravidarum) is another complication of pregnancy, which sometimes results fatally if the uterus is not emptied. There are cases, especially those with high fever, which end in death despite all treatment. Here, again, the aetiology of the disease is not known. There is commonly an element of hysteria in the condition, and in such a case moral suggestion often has a curative effect Any bodily irritation is to be removed. Eye-strain alone is enough to cause persistent vomiting. It is very difficult to decide when premature labour is absolutely indicated, because some very bad cases recover spontaneously when all hope is lost.
Hydramnios, or an excessive quantity ofliquor amnii,may so distend the uterus as to cause grave danger to maternal life, and if the child is viable the uterus should be emptied.
Intrauterine hemorrhage brought on by a premature separation of the placenta is a very dangerous condition: 32 to 50 per centum of the mothers die, and 85 to 94 per centum of the children. In a marked hemorrhage the only way to save the mother is to empty the uterus, so that it may contract and thus close the patulous vessels.
Placenta praevia is a placenta implanted in the neighbourhood of the internal os of the uterine neck. This is a very perilous condition, calling for the induction of premature labour. The medical treatment is artificial abortion as soon as the condition is diagnosed in any stage of gestation; but this is, of course, in conflict with the decrees of the Holy Office. Under expectant treatment about 40 per centum of{54}the mothers die, and 66 per centum of the children. Those children that are born alive commonly die within ten days after delivery. The great foetal mortality is due to premature birth and asphyxiation. Skilful obstetricians get much better results, but skilful obstetricians are unfortunately rare.
When the grave complications enumerated above occur in the early months of pregnancy, before the foetus is viable, the Catholic physician, since by the natural law and the decisions of the Holy Office he is forbidden to induce artificial abortion, must withdraw from the case. If there is no other physician to attend to the woman, he must let her die. He can not withdraw without explanation, and in many cases the explanation of the condition will promptly result in the calling in of a physician who has no scruple in inducing this abortion, no matter how reputable he may be. The universal medical doctrine is to induce abortion in cases where abortion will save the mother's life and the foetus is "too young to amount to anything." This is looked upon as legitimate abortion by the very best men that do not recognise the authority of the Holy Office: they deem the position of the Catholic physician in these cases as altogether erroneous, or even criminal.
The position of the Catholic moralists on craniotomy has turned the attention of many non-Catholic physicians to the immorality of the act, which formerly was deemed entirely permissible. Probably the same good result will be effected in the matter of abortion.
AUSTIN ÓMALLEY.
{55}
In the caesarean section the infant is delivered through an incision in the abdominal or uterine walls. The operation, according to one opinion, takes its name from Caius Julius Caesar, who, it is said, was brought into the world in this manner,"a caeso matris utero"; this, however, is a myth.
Up to 1876 the maternal mortality from the operation was about 52 per centum. Between 1787 and 1876 in the city of Paris there was not one successful caesarean section as far as the mothers were concerned. At present on an average less than 10 per centum of the women are lost, and expert surgeons have better results. Up to about 1902 Zweifel had made 76 such sections with only one death, and Reynolds, 23 with no death. Leopold has performed the operation four times on the same woman, and Ahlfeld and Birnbaum have reported instances where the same woman has had five caesarean sections performed upon her. The operation is, of course, capital, and always most serious, even in city hospitals.
The indication for the operation is chiefly a narrow pelvis, which blocks the delivery of the child. There are no reliable statistics as to the frequency of narrow pelves in the United States; but Dr. Williams, of the Johns Hopkins University Hospital, in a series of 2133 cases found 6.9 per centum in white women and 18.82 in negroes. Normally the average female pelvis, at its narrowest diameter, is 11 centimetres wide. This part is called the conjugata vera, and it is the diameter from the promontory of the sacrum behind to a point on the inner surface of the symphysis pubis in front.
In delivery much depends upon the size of the child, and in each case the obstetrician waits until he sees that delivery{56}is impossible by natural means before he resorts to the caesarean section or other operative interference. Of two women with pelves of the same contraction one may require the section and the other may have a normal labour. A bisischial diameter at the outlet of the parturient canal of 7 centimetres or less is an indication for section; so are certain tumours that block the delivery of the child.
When the conjugata vera is less than 7 centimetres in flat pelves, or 7.5 centimetres in generally contracted pelves, the treatment varies in the customary medical practice according as the child is alive or dead, and it varies as the condition of the mother. The common medical doctrine will first be given here before the moral questions that may be involved are mentioned.
If the deformity is diagnosed during pregnancy, the woman is sent to a hospital, the caesarean section is performed, and thus all the children, and nearly all the mothers, are saved. When the narrowness of the pelvis is discovered only during labour, the treatment varies with the condition. If the woman is not septic, and has not been repeatedly examined by the vagina, and if the surroundings are favourable, caesarean section is done; if she is septic, the indications are for the section, or symphyseotomy or craniotomy. Where the conjugata vera is below 5 centimetres in length, the caesarean section is the only method to get the child out, dead or alive, and after the child has been delivered, the uterus, if septic, is removed. If the conjugata vera is at the least 7 centimetres long, symphyseotomy may be done; if the conjugata vera is above 5 centimetres, the mother septic, and the child dead or dying, craniotomy is indicated. Even if the child is not dying, some obstetricians will do craniotomy.
In cases where the conjugata vera is above 7 centimetres in flat pelves and 7.5 centimetres in generally contracted pelves, the treatment can not be reduced to general rules. Delivery without operation occurs in many of these cases, but commonly the condition is obscure to the physician for some time. We can measure the pelves, but the size of the child's head is not satisfactorily measurable.
If the conjugata vera is from 10 to 9 centimetres, or from{57}9.5 to 8.5 centimetres, labour without operation is the rule, and the child can usually be delivered by forceps. Should the child die during labour in these cases, it is best delivered by craniotomy, unless the longer diameter of its head has already passed the narrowest part of the pelvis.
When the conjugata vera is from 8.9 to 7.5 centimetres, about 50 per centum of the women will be delivered with forceps, but the other half will not. After about two hours of the second stage of labour delivery by forceps is tried, but prolonged traction is not applied. Occasionally delivery will come when least expected, but often it will not. If the head sticks, caesarean section is done in favourable circumstances, and craniotomy in unfavourable circumstances. If there is ground for supposing that septic infection of the mother has begun, the conditions are explained, and if she wishes to have the caesarean section done the risk is left to her. When the breech or face of the child presents in contracted pelves, the condition is especially unfavourable for the child.
There are very many varieties of deformed pelves, but the same rules apply to them as to those already mentioned, except that the caesarean section is oftener indicated. Difficulty also not seldom occurs in women with normal pelves from an excessive size in the child through prolonged pregnancy, bigness of one or both parents, or the advanced age or multiparity of the mother. The child's head alone may be of excessive size. Some monsters offer difficulty in delivery from size or shape, but, of course, they are human beings, and are to be considered as such in delivery. The technique of the caesarean section has only a medical signification, and it need not be described here.
Symphyseotomy is an operation in which the joint of the pelvis at the symphysis pubis is cut, and the pelvis is allowed to gape so as to let out the child. The operation has fallen into disrepute. The mortality as regards the mother is about the same as in the caesarean section, but the mortality of the children is higher. In symphyseotomy the infantile mortality is about 9 per centum, while in the caesarean section it is practically nothing. If in symphyseotomy an error is made in estimating the size of the pelvis or the child's head—and{58}such an error is often possible—the child will be killed, but in the caesarean section these errors make no difference. After the caesarean section the woman recovers promptly; after the symphyseotomy she recovers very slowly, and she may receive permanent injury.
Craniotomy is an operation wherein the head of the child is reduced in size to render delivery possible. The skull is perforated and the brain is broken up and removed or crushed out. Embryotomy is a similar operation wherein the viscera of the child are removed through an incision made in its thorax or belly (evisceration), or the head of the child is cut off (decapitation). There are numerous instruments and methods for performing craniotomy and embryotomy, but they all open the skull or belly, remove the brain or viscera, and then extract the child's body.
If the infant is hydrocephalic and is alive, the advocates of the operation warn us to be careful after opening the head to push the perforator into the base of the skull and stir it around well, so as to be sure the child will not be born alive. Pernice has recently reported a case of hydrocephalus which was delivered by craniotomy, but the operator did not work his perforator efficiently, and the child recovered, and grew up an idiot. A similar case occurred in Baltimore.
The indications for craniotomy among those that advocate its occasional use (and they are many) is in those cases in which the woman is so infected that caesarean section is dangerous, or where a child is hydrocephalic, or where an after-coming head is jammed (in this case even a caesarean section will not effect delivery), or in the case of a narrow pelvis and a moribund child, or finally in the practice of a country physician, who can not in an emergency get an assistant to do a caesarean section. One man can do craniotomy, but it requires three to perform the caesarean section. If the woman's narrow pelvis has a conjugata vera of five or more centimetres, craniotomy, if properly done, is not dangerous to the mother. With a conjugata vera less than 5 centimetres it is more fatal than the caesarean section. If the women are septic, the mortality in{59}craniotomy is from 10 to 15 per centum; in caesarean section about 25 per centum.
As to the morality of craniotomy on the living or moribund child, it is not permissible under any possible circumstances: a consideration of the ethical principles set forth in the article on Ectopic Gestation will make this assertion clear.
The Congregation of the Holy Office on August 19, 1888, decreed that "In scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam Craniotomiam appellunt." They gave a similar decision May 28, 1884, and they repeated the prohibition, with the papal approbation, on July 24, 1895. The text of these decrees may be found in the article on abortion, miscarriage, and premature labour.
The Porro operation consists essentially in a removal of the uterus after caesarean section to prevent further conceptions. As a means to prevent conception it is altogether unjustifiable, because repeated caesarean sections in the same woman, if the surgeon is at all competent, are practically no more dangerous than normal labour.
AUSTIN ÓMALLEY.
{60}
There is a wide-spread persuasion that a child, while carried in the womb of its mother, may be marked as the result of incidents that produce violent impressions upon her nervous system. This is so old a conviction in the human race and would seem to be substantiated by so much evidence that it is extremely difficult to convince people that there is no scientific basis for it. As a matter of fact, however, there is something mysterious about the way in which certain things that happen to the mother seem to affect the childin utero. As the result of the common belief in the truth of maternal impressions, mothers sometimes are prone to blame themselves for not having been sufficiently circumspect during the time of their pregnancy, and accordingly they may seek advice and consolation in the matter from clergymen. Women sometimes become very much depressed as a consequence of an unfortunate event of this kind, and as the simple truth is the best possible source of consolation, it would seem that a special chapter should be given to the subject in a work of this kind.
The evidence for the truth of the theory of maternal impression is almost entirely due to peculiar coincidences. James I. of England, the son of Mary Queen of Scots, could never stand, according to Sir Walter Scott, the sight of a drawn sword with equanimity, and it is said even that he nearly fainted at his coronation because of an unexpected glimpse of some naked blades in the hands of courtiers. This peculiarity was attributed to the fact that his mother, while carrying himin utero,had witnessed the violent death of her secretary, the unfortunate David Rizzio. There have been, however, any{61}number of men who paled at the sight of a drawn sword before and since James I., with regard to whom no such circumstantial story could be told to account for it. There have been any number of women that have witnessed bloody murders under circumstances quite as heartrending as those surrounding Mary Queen of Scots and her secretary, and yet their offspring, though at the timein utero, have not been disturbed at the sight of drawn swords, nor of blood or any other circumstance connected with the deep impression that must have been produced on their mothers.
There is, of course, a striking instance related in the Old Testament, which seems to make it very clear that a belief in maternal impressions existed from the very earliest times among the Israelites. The story of Jacob is well known: "Jacob took him rods of green poplar and of the hazel and chestnut tree and pilled white streaks in them and made the white appear which was in the rods, and he set the rods which he had pilled before the flocks in the watering troughs when the flocks came to drink, and the flocks conceived before the rods and brought forth cattle, ring-streaked, speckled and spotted." In this case it seems evident that Jacob was not looking for a miracle, but was expecting that a law of nature would be fulfilled in the matter, the influence of the unusual sight upon the animal mothers proving sufficient to have a definite effect upon their unborn offspring. The most ardent advocates of the power of maternal impressions would scarcely concede the existence of as much influence as this of the mother's mind over the child unborn, otherwise there would surely be a very absurd collection of anomalous births in the race.
On the other hand, it is generally conceded that the mother's habitual temper of mind and the thoughts with which she occupies herself may influence her unborn offspring to a most marked degree. The story is told of a child-murderer who delighted in fiendish deeds of cruelty and had murdered many people in cold blood, that his mother, the wife of a butcher, had delighted in watching the operation of slaughtering during the course of her pregnancy. There are any number of women, however, who have, by the necessities{62}of their occupation, had to witness the shedding of animal blood under such circumstances and yet without any special effect being noticeable in their offspring. It has been said that the opposite is also true, and that if a woman occupies herself with high and lofty thoughts, with noble deeds and unselfish devotion to others and if she occupies her mind and senses with the great works of art, a correspondingly beneficial effect will be noted upon the character of the foetus. These are, however, abstruse speculations leading to conclusions not founded upon actual observation, but upon theorising over the supposed fitness of things.
Coincidence plays such a large part in the matter of supposed maternal impressions that it is impossible to decide how much there is of fact and of consequence in the many stories that are told. Most women are a little afraid, as the time of their labour approaches, lest something or other—usually of an indefinite nature—that has happened during their pregnancy, may cause the marking of their child. When they find that the child is perfectly normal, they breathe a sigh of relief and forget all about it. If any anomaly is noted, however, then they are sure to connect it with some incident during pregnancy, and imagination is apt to lend details that confirm the supposed connection. On the other hand, there are not a few cases in which such anomalies have occurred, and good, sensible mothers have been unable to recall anything that might possibly serve to account for the peculiarity noticed in the child, though corresponding peculiarities in other children were supposed to be readily traceable to maternal impression. Even where there has been no foreboding of evil results, something or other that has occurred during the pregnancy will often be magnified enough by memory to account for the supposed maternal impression.
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 attitude 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 pass 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 prone 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 circumstances, 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 passed 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 repetition of certain{66}village gossip which by no means loses its point or effectiveness passing 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 childin 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 constitution 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 constitutes 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 pass 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 pass. It seems impossible to explain, then, how maternal impressions can so effectively pass 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.
{68}
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 beingin uterois 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.
{69}
Teratology (, 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 predicunt."
At the end of the seventeenth century Malpighi and Grew discovered that plant tissue is entirely made up of microscopic spaces enclosing fluid; they called these spacescells. 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 pronuclei. 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 principal 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 breasts, 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 multitude, 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, andvice 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 class, 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 principal 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 principal part, and lies in a clear fluid. Without the spiral filament, along the middle piece, is the mitochondria, a finely granular protoplasmic layer. The principal 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 aMorula,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 theBlastodermic Vesicle,is formed.The next stage in development is the establishment of two primary germinal layers, called together theGastrula, The outer layer is theEctodermor theEpiblast,and the inner layer is theEndodermorHypoblast. 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 theMesodermorMesoblastis 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 classification of Hirst and Piersol (Human Monstrosities, Philadelphia, 1891), which is a combination and change of the classifications of Geoffrey Saint-Hilaire, Klebs, and Förster, 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 testicle, and other rudimentary sexual organs that belonged to both male and female. Forms of apparent doubling are common, and in case of doubt as to sex 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 sex; 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 theparacephalushas an imperfect head, commonly no heart, and the lungs are absent or rudimentary. Theacephalushas no head, and commonly no arms; theasomatais 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—thefoetus anideus. This is a shapeless mass of flesh covered with skin. There may be a{76}slight prominence with a tuft of hair on it at one end of the mass to indicate the head. In this monster there are more traces of bodily organs than might be expected. These four kinds of omphalosites are either dead when born, or they die as soon as the placental circulation is cut off. If there is any probability of life, the physician should give them baptism before the placental circulation is stopped.
Nothing satisfactory is known concerning the etiology of single monsters. Landau, and other authorities as great as he is, reject the theory that maternal impressions from fright or exposure to the sight of hideous deformity are the cause of terata. I think the father is accountable for terata as often as the mother is. Barnes, an English physician, and others claim they find that terata are frequent in consanguineous marriages, but I have not been able to verify the assertion.It seems a theory may be offered to explain the single terata. In 1888 Roux of Breslau by puncturing one blastomere of a frog's egg in the two-cell stage killed the punctured blastomere without affecting the other. The punctured blastomere remained inactive, but the other developed into a completehalfembryo.Crampton by separating and isolating the blastomeres in the two-cell stage obtained a half embryo; and Zoja by isolating blastomeres of the medusae, Clytia and Laodice, gotdwarfedlarvae.Wilson succeeded by the separation through shaking of the blastomeres in the two-cell and four-cell stages in developing Amphioxus larvae, which were half the natural size for the two-cell blastomeres, and commonly half the normal size from the four-cell blastomeres, yet in the latter some of the larvae were of the normal size butimperfect. From the eight-cell stage he got only imperfect larvae. Similar results were obtained by other operators with various eggs.Driesch and Morgan by removing part of the cytoplasm from a fertilized egg of the ctenophore, Beroe, produced imperfect larvae showing certain defects which represent the parts removed.In these cases of injured and isolated blastomeres we have, it seems to me, a plausible theory for the etiology of single terata. The blastomeres in the human ovum may perhaps be injured in part by toxins from the mother, or they may be defective through disease in the ovum or the spermatozoon. They also may possibly be displaced traumatically, but this seems to be doubtful.There are three theories concerning the origin of omphalositic{77}terata. Ahlfeld (Missbildungen des Menschen, Leipsic, 1882) holds that the autosite is stronger than the omphalosite, and as a consequence the foetal circulation in the omphalosite is reversed, and development is thus checked. Dareste (Production artificielle des monstruosités, Paris, 1876), Panum (Beitrag zur Kenntniss der physiol. Bedeut. der angeboren Missbildungen, Virchow's Archiv.,1878), Perls (Lehrbuch der allgem. Pathologie) and Breus (Wiener med. Jahrbuch, 1882) maintain there is an inherent original defect in the omphalositic child which prevents development of the blood-vessels, and that Ahlfeld's theory of an indirect umbilical connection of the omphalosite to the placenta is not probable; if it were, omphalosites would be very common, because one of twins is nearly always stronger than the other. Hirst and Piersol (op. cit) combine these theories. This kind of monster is certainly an imperfectly developed human individual, and even the Foetus Anideus should receive at the least conditional baptism.
The next group comprises the composite monsters. Normal twins may arise from the fertilisation of one ovum and of two distinct ova. In 506 cases examined by Ahlfeld he found that 66 twin births came from single ova. Twins from a single ovum are always of the same sex, and they are not easily distinguished one from the other. Triplets may arise from one, two, or three ova. The elder Saint-Hilaire thought that composite monsters arise from the fusion of two impregnated ova, but this opinion is now generally rejected. Composite terata in every instance arise from a single ovum.
There is a divergence of opinion, however, as to the origin of a composite monster in the single ovum. Some authorities maintain that these monsters arise from the union of two originally separate primitive traces. This supposes primitive duality followed by fusion (Verwachsungstheorie). Other writers hold that there is originally one primitive trace, and that composite terata are the product of a more or less extensive cleavage of this single blastoderm. This supposes primitive unity followed by fission (Spaltungstheorie). Here, as in the case of normal development, the argument is founded on analogy. The earliest stage in the development of a human double monster observed was at the fourth week after fertilisation—Ahlfeld's case.B. Schultze (U. anomale Duplicität der Axenorgane, Virchow's Archiv.) and Panum and Dareste (op. cit.) hold the fusion theory—{78}the fusion of two separate blastoderms in one ovum. Panum and Dareste have seen two separate normal blastoderms on one ovum. Allen Thompson in 1844 (London and Edinburgh Monthly Journal of Medical Science), Wolff, von Baer, and Reichert also observed two embryos in one ovum. Dareste is of the opinion that the fusion of two separate ova is impossible. The fission theory—the fission of a single blastoderm to make a composite monster—is supported by Wolff, J. F. Meckel, von Baer, J. Müller, Valentine, Bischoff, and others, especially by Ahlfeld. Ahlfeld says that this single blastoderm is split by pressure.Gerlach also (Die Entstehungsweise der Doppelmissbildungen, etc.,Stuttgart, 1882) admits fission, but he contends that it is not so simple a process as Ahlfeld thinks it is. It is not a passive cleavage, but a result of a force in the cell-mass existing before differentiation. Gerlach calls fission at the anterior or head-end of the single blastoderm,bifurcation; and he has actually observed such bifurcation in a chick embryo of sixteen hours (U. d. Entstehungsweise der vorderen Verdoppelung. Deutsche Archiv. f. klin, Med.,1887). In this case the first change noticed was a broadening of the anterior end of the primitive streak; next a forked divergence appeared, and this became more pronounced; until by the twenty-sixth hour the bifurcation was half as long as the undivided posterior part. From each anterior end of the diverging branches a distinct head-process extended. Allen Thompson (loc. cit.) in 1844 saw a goose-egg, which had been incubated for five days, in which was a double monster divided to the neck.Beyond this observation by Gerlach we have the fact, which seems to make for the fission theory, that no matter how unequally nourished or how variable in extent, the union between the halves of double monsters is always symmetric—exactly the same parts of each twin are joined. This seems to exclude a fortuitous growing together of dissimilar areas or cell-masses, for non-parasitic double terata at the least. Born (U. d. Furchung des Eies bei Doppelbildungen, Breslauer Aerztl. Zeitschr., 1887), in a study of fish ova, found that ova which produce double monsters begin with a segmentation like that of the single normal ovum.If fission is complete homogeneous twins are the result; these twins are of the same sex and very similar in appearance. Incomplete fission, as has been said, gives rise to double or triple terata. If one of the teratic twin embryos is stronger than the other, the various combinations of enclosure and parasitism may result, although the origin of parasitic double terata is not convincingly clear. A triple{79}monster, according to the fission theory, arises from a double incomplete cleavage of the primitive trace. Dr. Ephraim Cutter has observed teratic composite spermatozoa which, he thinks, probably have influence in producing composite monsters.
There are three orders of the double autositic monsters:Terata Katadidyma,in which the embryonal fission was at the cerebral end; theTerata Anadidyma, divided below; theTerata Anakatadidyma, divided above and below, but joined at the middle of the body. There are four genera of the Terata Katadidyma with many species. The first genus is theDiprosopus,the double-faced. The doubling varies from the finding of two complete faces to a slight trace of duplex formation in one head. Förster in 500 human monsters observed 29 cases of diprosopi.
There are six species of diprosopi: 1.D. Diophthalmus,which has only two eyes, but there is a doubling of the nose. 2.D. Distomus, which has two mouths, two lower jaws, two tongues, one pharynx, and one oesophagus. 3.D. Triophthalmus, which has three eyes, and the doubling of the face is more complete. There are only two ears. 4.D. Tetrophthalmus, which has four eyes and two well-separated faces. 5.D. Triotusis like the last, but it has three ears. 6.D. Tetrotushas four ears, four eyes, and there is some doubling at the pharynx. Two oesophaguses enter one stomach in this species commonly. D. Tetrotus is rare—only one example in man is known. In all diprosopi there is only one trunk, one pair of arms, and one pair of legs. Sir James Paget had a photograph, made in 1856, of a living diprosopus, the second face of which had a mouth, nose, eye, part of an ear, and a brain (?) of its own. The two faces acted simultaneously, suckled, sneezed, yawned together.
Are diprosopi twins? An answer to this question will be clearer after a description of other composite terata.
The second genus of the Terata Katadidyma is theDicephalus. This genus comprises five species, which have in each case two heads, with separate necks commonly. There are two vertebral columns, which usually are separate down to the sacrum, and they converge at the lower end.{80}In the interior organs doubling will be found corresponding to the degree of separation of the trunks. In all the species of this genus there are one umbilicus and one cord.
The first species of the Dicephalus is theDicephalus Dibrachius—a two-armed, double-headed monster. In this species most of the viscera are single, but the right and left halves of each viscus are supplied by the respective foetuses, and the entrail does not become indistinguishably single until near the lower end of the ileum. There may be two ordinary kidneys and a third smaller one, two pancreatic glands, and two gall-bladders. Such a monster may be monauchenous or diauchenous.
The next species is theDicephalus Tribrachius Dipus—two heads, three arms, and two legs. There is also aDicephalus Tribrachius Tripus(three arms and three legs),D. Tetrabrachius Dipus(four arms and two legs), andD. Tetrabrachius Tripus(four arms and three legs). In all these cases there is no doubt of the presence of twins, unless there might be some doubt as to dual personality in the Dicephalus Dibrachius. In the Dicephalus Tetrabrachius Dipus and the Dicephalus Tetrabrachius Tripus there is almost complete duplication of the internal organs, and the halves of the composite body belong evidently to individuals distinct in thought, volition, and character. Each brain controls only its own half of the body. There are four lungs, two hearts (sometimes in one pericardium), two stomachs, two intestinal canals down to the colon or lower, two livers (sometimes joined), four kidneys (or three, one of which is small), two bladders, emptied at different times through a common urethra.
Dicephali are somewhat common. Förster found 140 among 500 specimens of monsters. They are rarely born alive. The best known cases of dicephali that lived for any length of time are:
1. Peter and Paul, of Florence, born in 1316, lived thirty days.
2. The Scotch Brothers, born in 1490, lived twenty-eight years. They were at the court of James III. Above the point of union the twins were independent in sensation and action, but below the point all sensation and action were{81}common. One died before the other, and the second "succumbed to infection from putrefaction" a few days later.
3. The Würtemberg Sisters, born in 1498.
4. The twins, Justina and Dorothea, born in 1627, lived six weeks.
5. Boy twins at Padua, born in 1691, lived to be baptised.
6. Rita-Cristina, born at Sassari in Sardinia in 1829. They lived eight months. These children had a common trunk below the breast, one pelvis, and one pair of legs. Rita was feeble and quiet, Cristina vigorous and lively. They suckled at different times; and sensation in the heads and arms was individual, but below the junction it was common. Rita died of bronchitis, and during Rita's final illness Cristina was healthy; but when Rita died, Cristina, who was suckling at the time, suddenly expired. They had two hearts in one pericardium, the digestive tracts did not fuse until the lowest third of the ileum was reached. The livers were fused, the vertebral columns were distinct throughout. These twins were baptised separately.
7. Marie-Rose Drouin, born in Montreal in 1878. They lived seven months. Marie died of cholera infantum; and Rose then died, although she had not been directly affected by the disease. These twins were like Rita-Cristina anatomically except that they had no legs. The respirations and heart-pulsations differed, and one child slept while the other child cried.
8. The Tocci boys, born in Turin in 1877. In 1882 they were strong and healthy, and they may be living still. They resembled Rita-Cristina anatomically in every respect. Each boy had control of the leg on his own side, but not of the other leg, consequently they could not walk. Their sensations above the juncture were distinct, and their thoughts and emotions differed.
In the ParisL'union médicalethere is an account of a bicephalic still-born monster, born at Alexandria in 1848, which, according to the report, had on one side a typical negro head and on the other side a typical Egyptian fellah head. This report is probably not authentic; but if it is, it would be difficult to reconcile it with the fission theory.{82}Supposing the report true, the case would have to be one (1) of superimpregnation wherein (2) a spermatozoon from each source penetrated the same ovum, (3) a bicephalic monster resulted, with (4) distinct racial characteristics. All this is extremely improbable.
Superimpregnation has happened. There are cases where negresses have given birth to twins, one of which was a negro and the other a mulatto. Instances are cited in books on Legal Medicine like those of Tidy and Beck. In Flint's Physiology a case is recorded in which a mulatto woman in Kent County, Virginia, married to a negro, gave birth to twins, in 1867, one of which was a negro much blacker than the mother, and the other a white child, with long, light, silky hair, and a "brilliant complexion." The white child's nose was shaped like the mother's, but there was no other resemblance. Even supposing this to be a case of superimpregnation, that does not fully explain the extreme whiteness of one child and the extreme blackness of the other.
Superfoetation is also possible. Tidy (Legal Medicine) gives a case: "Mary Anne Bigaud, at thirty-seven, on April 30th, 1748, gave birth to a full-term mature boy, which survived its birth two and a half months, and to a second mature child (girl) on September 16th, 1748, which lived for one year." The second child was born four and a half months after the first, and both were "nine-months" children. It was proved after death in this case that the mother had not a double uterus, and the report is vouched for by Professor Eisenman, and by Leriche, surgeon-major of the Strasburg Military Hospital. Several other cases of superfoetation are given by Bonnar (Edin. Med. Journ.,January, 1865).