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 Duplicitaet 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. Mueller, 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;
the _Terata Anadidyma_, divided below; the _Terata 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 the _Diprosopus,_ the double-faced. The doubling varies from
the finding of two complete faces to a slight trace of duplex
formation in one head. Foerster 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. Triotus_ is like the last, but it has three ears. 6. _D. Tetrotus_
has 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 the _Dicephalus_. 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 the _Dicephalus 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 the _Dicephalus Tribrachius Dipus_--two heads,
three arms, and two legs. There is also a _Dicephalus Tribrachius
Tripus_ (three arms and three legs), _D. Tetrabrachius Dipus_ (four
arms and two legs), and _D. 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. Foerster 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 Wuertemberg 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 Paris _L'union medicale_ there 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).
The third genus of Terata Katadidyma is the _Ischiopagus_. These twins
are divided so much from above downward that the heads are at almost
opposite ends of the double body. They are joined at the coccyges and
sacra, and the spinal columns have nearly the same axis. The trunk
organs are complete and separate, except that they are commonly fused
in the pelvis. There may be two, three, or four legs, given off at
right angles to the pelvis. This kind of monster is not rare. Foerster
collected twenty cases, and nine new examples {83} were reported in
the _Index Medicus_ between 1879 and 1893. Ischiopagic twins were born
in County Roscommon, Ireland, in 1827, and baptised separately. The
Jones Twins, born in Typhon County, Indiana, in 1889, lived for about
two years; they were ischiopagi, and they had the very unusual
quality, it is said, that they differed in complexion and the colour
of eyes and hair. A case was reported in _American Medicine_,
September, 1903.
Classed with the Katadidyma is the genus _Pygopagus_, although it has
four legs. This form is very rare. The twins are joined only by the
latero-posterior aspects of the sacra and coccyges, so that the two
individuals are placed almost back to back. The trunk organs are
independent, except for some fusion near the point of juncture.
Examples of this class are the Hungarian Sisters, born at Szony in
1701, who lived to womanhood; the negresses Millie-Christine, born in
1851, and who were recently living in North Carolina; and the Blazek
Sisters of Bohemia. The negresses had common sensation in the legs,
but Millie could not localise what part of Christine's legs was
touched, and _vice versa_.
The second group of the double autositic monsters are _Terata
Anadidyma_--terata divided from below upward. The first genus is the
_Dipygus_. This has a single body above, but a double pelvis with
double lower extremities in the typical cases. There is an exact
description of a double monster of this kind in the Gaelic _Annals of
the Four Masters_ as early as the year 727 of this era. The chronicler
says in that year on Dalkey Island near Dublin, "There was a cow seen
which had one head and one body as far as her shoulders, two bodies
from her shoulders hindward, and two tails. She had eight legs, and
she was milked three times a day."
A perfect human Dipygus with two equally developed pairs of legs is
unknown. Catherine Kaufmann, who was born in 1876, and who died in
1878, had a double pelvis with double pelvic organs in part, but she
had only one pair of legs. There is a similar anomaly said to be
living in Philadelphia at present. Blanche Dumas, born in 1860, had a
double pelvis, double pelvic organs, and three legs. Mrs. B., born in
1868, {84} had four legs--the two inner ones were smaller than the
outer pair. Her spinal column was divided up to the third lumbar
vertebra. Her double pelvic organs acted independently. There are
living male examples of this form of monster.
The next genus is the _Syncephalus_, called also _Janus_ and
_Janiceps_. Its lower body is double up to the umbilicus, the trunk
single above that point; the head shows signs of doubling, and there
are four legs and four arms; the bodies grow front to front. The head
usually is large, therefore this monster is born dead.
Another genus is the _Craniopagus_--twins joined only by the skull or
scalp. There are three species, named from the place of
union--_Craniopagus Frontalis, C. Parietalis_, and _C. Occipitalis_.
A third group of double autositic monsters are the _Terata
Anakatadidyma_, which are divided above and below, but joined from the
navel to the head. There are three genera. The first, the
_Prosopothoracopagus_, is joined at the upper abdomen, the chest, and
the faces; the spinal columns are separate. The faces are imperfect,
the jaws are united; there is a broad neck with one oesophagus, and
there is one stomach and one duodenum. This is a rare form, and it can
not exist out of the uterus.
A second genus, the _Thoracopagus_, has a thorax in common, and the
inner legs may be united. It is, as a rule, still-born.
The next genus is the _Omphalopagus_, in which the twins are joined
from the navel to the bottom of the chest. This double monster has the
slightest union of all, and it is very rare. The Siamese Twins were
omphalopagi. They quarrelled; one became a drunkard and the other
remained temperate. They married two women, and Chang had ten
children, and Eng twelve. Chang died while Eng was asleep, and the
latter died two hours after he had waked and learned of his brother's
death.
There is a genus, the _Rachipagus_, the examples of which are joined
behind like the class Terata Anakatadidyma that are joined in front.
{85}
Four known attempts have been made to separate double monsters
surgically, but all failed owing to crude surgery; modern methods
might be successful in some cases.
The second order of double monsters comprises the parasitic class.
There are three genera of these terata, with five species and
seventeen varieties. The chief of these only will be mentioned. The
_Heterotypus_ is a parasitic child which hangs from the abdominal wall
of the principal subject. Varieties of this species are the
_Heteropagus_, which is a parasite with head and arms; the
_Heterodelphus_, which has no head; the _Heterodymus_, which has a
head, neck, and thorax. The _Heteralitis_ is a second species, in
which the parasite is inserted at a distance from the navel of the
autosite. The _Epicomus_ is the only example, and it consists of a
parasitic supernumerary head. The _Polypnathus_ is a parasite attached
to the jaw of the autosite. When fastened to the upper jaw, it is an
_Epignathus_; at the lower jaw it is an _Hypognathns_. Another group
is made up of terata having parasitic legs which are attached to
different parts of the autosite,--to the pelvis, the head, the
abdomen, and so on. Finally, there is the _Endocyma_, which is a
parasite enclosed within the body of an autosite.
Parasites are nourished through the blood supply of the autosite, and
the parasites usually are incapable of motion. The autosite can feel
when the parasite is touched, and in some cases the autosite can
localise the touch. In India, in 1783, a child was born which had a
supernumerary head attached to the autositic head, crown to crown; it
lived four years. The parasite's eyes were always partly open, but
they appeared to be incapable of intelligent vision. They contracted
under strong light, and when the autosite was suddenly awakened both
sets of eyes moved.
Gould and Pyle (_Anomalies and Curiosities of Medicine_) give an
account of an Italian boy, aged eight years, who had a small parasitic
head protruding from near the left third rib. Sensibility was common.
Each of the heads received baptism (one was called John and the other
Matthew), and there was question as to whether extreme unction should
be administered to the parasitic head. A similar case occurred in {86}
England in 1880 (_British Med. Journal_), and the parasitic head could
be pinched without attracting the attention of the autosite.
Teratologists now exclude Dermoid Cysts from the lists of terata. The
hair, teeth, and particles of bone found in these cysts are looked
upon as the development of abnormal ectodermic and endodermic cells,
rather than as evidence of a separate personality.
There is only one well-authenticated case of a triple monster, and
this happened in Italy in 1831. The monster had a single broad body
with three distinct heads and two necks. It was killed in delivery.
In Katadidyma (terata divided from above downward), when we have
dicephali, ischiopagi, or pygopagi, there are evidently two
individuals present. Is the Diprosopus, however, the two-faced
monster, possessed of one or two souls? The cases vary, as we said,
from examples with two distinct faces and four ears to cases that have
merely two noses. What portion of a human body is required to contain
a new soul? That is an interesting question for the psychologist and a
very practical one for the moralist, and no moralist has yet attempted
to solve it. The presence of a brain is not essential, because
acephalous monsters develop without brain, and they are born alive;
they have a vital principle which is identical with the soul.
Among the Terata Anadidyma (divided from below upward) the Syncephalus
and the Craniopagus are unquestionably two persons. Is the Dipygus
(single down to the navel, double below) one or two persons? Mrs. B.,
the example already given, was as double below the navel as any
Dicephalus is above that point. She had features so well ordered in
unity that she was a pretty woman, but that unity ceased at her waist.
Was her husband unknowingly a bigamist? I think he was. After a
consideration of the fission of terata, and the non-essential quality
of the brain, why should fission that started at the feet differ from
fission that started at the head?
In the _Rituale Romanum Pauli V._ (tit. ii. cap. i. nn. 18, 19, 20,
21), the following directions for the baptising of terata are given:
{87}
18. In monstris vero baptizandis, si casus eveniat, magna cautio
adhibenda est, de quo si opus fuerit, Ordinarius loci; vel alii
periti consulantur, nisi mortis periculum immineat.
19. Monstrum, quod humanam speciem non praeseferat, baptizari non
debet; de quo si dubium fuerit, baptizetur sub hac conditione: _Si
tu es homo, ego te baptizo,_ etc.
20. lllud vero, de quo dubium est, una ne, aut plures sint personae,
non baptizetur, donec id discernatur: discerni autem potest, si
habeat unum vel plura capita, unum vel plura pectora; tunc enim
totidem erunt corda et animae, hominesque distincti, et eo casu
singuli seorsum sunt baptizandi, unicuique dicendo: _Ego te
baptizo_, etc Si vero periculum mortis immineat, tempusque non
suppetat, ut singuli separatim baptizentur, potent minister
singulorum capitibus aquam infundens omnes simul baptizari, dicendo:
_Ego vos baptizo_, in nomine Patris, et Filii, et Spiritus sancti.
Quam tamen formam in iis solum, et in aliis similibus mortis
periculis, ad plures simul baptizandos, et ubi tempus non patitur,
ut singuli separatim baptizentur, alias numquam, licet adhibere.
21. Quando vero non est certum in monstro esse duas personas, ut
quia duo capita et duo pectora non habet distincta; tunc debet
primum unus absolute baptizari, et postea alter sub conditione, hoc
modo: _Si non es baptizatus, ego te baptizo in nomine Patris, et
Filii, et Spiritus sancti._
AUSTIN OMALLEY.
{88}
VII
SOCIAL MEDICINE
The influence of the clergyman or the charitable visitor in matters of
health and sanitation can scarcely be overestimated. The removal of
prejudices with regard to sanitary regulations for the prevention of
disease and modern advances in the treatment of disease is an
important social duty. There is no doubt that if this influence be
properly directed, sanitary measures of various kinds will be much
more readily enforced and the precautions necessary to prevent the
spread of serious infectious ailments more faithfully observed. As
this amelioration of sanitary conditions will affect mainly the poor,
lessening their suffering and adding to their possibilities of
happiness, its accomplishment becomes a great Christian duty,
obligatory on all those who are interested in the uplifting of the
poorer classes.