This experiment helps to explain why some infants, such as Hermann Unthan, are born without arms or legs. Our limb-buds also have apical ectodermal ridges, and sometimes they must surely fail. The ridges on Hermann’s arm-buds probably malfunctioned soon after they first appeared; perhaps they never appeared at all. Other human deformities resemble the less extreme amputations seen in chicks whose wing ridges are removed only late in their growth. In the Brazilian states of Minas Gerais, São Paulo and Bahia there are families who are afflicted with a disorder called acheiropody – from the Greek: a – absence, cheiros – hand, podos – foot. Instead of hands and feet, the victims of this disorder have limbs that terminate in a tapered stump. They get about by walking on their knees and are called by the locals aleijadinhos, or ‘little cripples’. The disorder is caused by a recessive mutation, probably quite an old one since it appears in more than twenty families, all of Portuguese descent. Because the mutation is recessive, only foetuses who have two copies of the mutant gene fail to develop hands and feet. Having two copies of a mutation is usually a sign of inbreeding: the first family of aleijadinhos ever studied were the children of a Peramá couple who were – local opinion varied – either full siblings, half siblings, or else uncle and niece.
The apical ectodermal ridge is the sculptor of the limb. As the development of the limb-bud draws to a close, the ridge regresses, leaving behind an outline of our fingers and toes. Should it be damaged in any way, the consequences will be visible in the limb’s final form. The ectrodactylous hands of the Wigtown cleppies were the result of a mutation that caused a gap in the middle of the ridge, and so a gap in the middle of the forming limb. Mutations in at least four different genes are known to cause ectrodactyly, but it is quite possible that more will be discovered.
What gives the ridge, which is little more than a clump of cells, such power over the shape of a limb? The most obvious explanation would be that the cells making up the tissues of the limb – bone, sinew, blood vessels and so on – have their origin in the ridge. But this is not the case. All of these tissues are made of the mesoderm that lies beneath the ridge rather than the ridge itself; only the skin is ectoderm. The obvious alternative is that the ridge matters not as a source of cells, but rather as a source of information: it tells mesoderm what to do.
Action at a distance in the embryo usually implies the work of signals, and so it is in the limb-bud. Apical ectodermal ridges are rich in signalling molecules, especially so in one family of them: the fibroblast growth factors or FGFs. The experiment that identified FGFs as the source of the ridge’s power began with the surgical extirpation, à la Saunders, of the apical ectodermal ridge from the tip of a young wing-bud. The denuded bud was not, however, allowed to grow up into the usual amputee wing. Instead, a silicone bead soaked in FGF was placed on its tip, more or less where the ridge would be. The result was a fully-grown limb – one cured, if you will, by the application of a single protein. Twenty-two genes in the human genome encode FGFs, of which at least four are switched on in the ridge. No one knows why so many are needed there, but collectively they are vital to the workings of the ridge. It would be an exaggeration to say that to grow a leg or an arm one needs only a little FGF, but clearly a little goes a long way.
Ridge FGFs not only keep mesodermal cells proliferating, they also keep them alive. Many cells will, at the slightest provocation, commit suicide. They have a whole molecular machinery to assist them in doing away with themselves. Seen through a microscope, a cell suicide is spectacular. Over the course of an hour or so the doomed cell becomes opaque, then suddenly shrivels and disappears as it is consumed by surrounding cells. In the limb-bud, FGFs block the machinery of death; they give cells a reason to live. Yet while mass cell suicide is clearly a bad thing, at least some cell death is needed to form our fingers and toes, for if the ridge is the sculptor of the limb, cell death is the chisel. At day 37 after conception our extremities are as webbed as the feet of a duck. Over the next few days the cells in the webs die (as they do not in ducks) so that our digits may live free. Should a foetus have too much FGF signalling in its limbs, cells that should die don’t. Such a foetus, or rather the child it becomes, has fingers and toes bound together so that the hand or foot looks as if it is wearing a mitten made of skin.
When Saunders removed the apical ectodermal ridge from a young limb-bud, the result was total amputation. Yet if the bud was older and larger, then only the structures further down – wrists, digits – were lost. Why? Over the last fifty years, various answers have been given to this question. The latest, though surely not the last, turns on two quite new observations. The first of these is that the ridge FGFs only penetrate a short way, about two hundred microns (one fifth of a millimetre) into the mesoderm. In a young limb-bud, two hundred microns-worth of seceding cells cuts very deep as a proportion of total mass; in an older, larger limb-bud, much less so. This difference in proportion matters because limb-buds possess an invisible order. A limb-bud may look like an amorphous sack of cells, but even when newly formed, when it is no more than a bump on the foetal flank, its mesodermal cells have some foreknowledge of their fates. Some are already destined to become a humerus, others digits, yet others the parts between. As the limb-bud grows, each of these populations of cells proliferates and expands in turn. When a young limb-bud is deprived of FGFs, all of these variously fated cell populations suffer; when an older limb-bud is deprived only those closest to the tip do, and with them future hands and feet, toes and fingers.
This account of the making of our limbs contains within it the roots of twentieth-century medicine’s most infamous blunder. In 1961 an Australian physician, William McBride, reported a sudden surge in the numbers of infants born with deformed limbs. Similar findings were reported a few months later by a German named Lenz. Both physicians suggested that the defects were caused by a sedative used to prevent morning sickness that has the chemical name phtalimido-glutarimide, but which swiftly became notorious by its trade-name, thalidomide. More reports rolled in from around the world. By the time it was all over, more than ten thousand infants in forty-six countries with thalidomide-induced teratologies had been found. Only the United States escaped the epidemic because a few sceptical FDA officials had delayed authorisation of a drug that was, at the time, the third best-selling in Europe.
The thalidomide infants had a very particular kind of limb deformity. Unlike acheiropods, their limbs did not suggest amputations in the womb, for most had reasonably formed hands and feet as well as shoulderblades and pelvises; they were simply missing everything else in between. Without long bones, their arms and feet connected almost directly to their torsos. Their limbs had the appearance of flippers – a condition dubbed phocomelia or ‘seal-limb’.
Phocomelic infants have always appeared sporadically. In the sketchbooks of Goya (1746–1828), that compassionate connoisseur of deformity, there is a lovely sepia-wash portrait of a young mother proudly displaying her deformed child to two inquisitive old women. And there are, scattered throughout the early teratological literature, any number of people with the disorder. In his Tabulae (1844–49), Willem Vrolik gave a portrait of a phocomelic, a famous eighteenth-century Parisian juggler, Marc Cazotte, also known as ‘Le Petit Pepin’. Vrolik also shows Cazotte’s skeleton, which still hangs in the Musée Duputryen in Paris, though its legs, by sad irony, are now missing. These cases of phocomelia might have been caused by some chemical or other, but they may also have been due to mutations, several of which cause the disorder. But until the 1960s, phocomelics were rare, little more than anatomical curiosities. Thalidomide turned them into icons of medical hubris.