THE 
Obstetrical and Surgical Management, 
WITH 
REMARKS. 
BY A. B. COOK, A.M., M.D., 
Professor of the Principles and Practice of Surgery, Kentucky ScJwol of 
Medicine, Louisville, Ky. 
LOUISVILLE, KY.: 
BELL <S CO., PRINTERS, 111 WEST GREEN STREET. 
1869. . Medical JournoU of 
i mid Louisville Mti 
Fr„n, the Richmond lW». JOINED TWINS: 
THE 
Obstetrical and Surgical Management, 
WITH REMARKS. 
BY A. B. COOK, A. M., M. D., 
Professor of the Principles and Practice of Surgery, Kentucky School 
of Medicine, Louisville, Ky 
In the human organism, a monstrosity—something out 
of the common order of nature—has, in all ages, been 
of frequent occurrence. We would exclude from this 
general definition, abnormal developments, such as club- 
foot, supernumerary toes and fingers, cleft-palate, &c., and 
limit the term to the complex anomalies of conformation. 
In the days of mythology, monstrous births were re 
garded as omens of evil, the displeasure of God or the 
(5) 2 
work of tlie evil spirit. The laws of ancient Greece and 
Rome required them to be put to death ; even as late as 
the seventeenth century, they were either killed or se- 
cluded from sight, and in this century, in some countries, 
they were confined in certain limits. Happily for this 
unfortunate class of beings, with the light of science— 
the guiding and unerring star of hope—a brighter day 
dawned. In this enlightened century, they are by the 
general public, gazed upon only as curiosities; pander- 
ing to a morbid taste to see the irremediable deformities 
of a fellow-being. To the lover of medical science, whose 
mission now is : First, to acquaint himself with the struc- 
ture of the human body and the sciences based thereon; 
next, to know when to interfere with and when to let 
nature have her course; they present a study of peculiar 
interest in the departments of anatomy, physiology, path- 
ology, obstetrics and surgery. 
Three theories have been advanced to account for the 
cause of double monster, which Yorlick states as follows:* 
First. The double monster is supposed to have pro- 
ceeded from two distinct embryos, which have become 
united in the course of development. 
Second. It has been thought to originate in a single 
germ, which has become double, or has become subdi- 
vided. 
Third. The germ has been regarded as abnormally 
compound from the beginning, implying that the organs 
and parts composing the double monster are at once pro- 
duced from this germ, without either separation or coali- 
tion of its parts, other than belongs to the natural process 
of development. 
Of these theories, it would appear to the writer, that 
the third is the most natural and rational—that double 
Transactions, Yol. II. 3 
monsters are ab ovo—developed from an original double 
germ. The first is discarded from the fact that double- 
yolked eggs, when brought to incubation, as was done by 
Prof. Allan Thompson, M.D., never produced joined 
twins. Uor would this mode of production account for 
one or more of the vital organs being common to the two, 
while all the other organs are duplicated. The second 
theory predicated on the division of a single germ, ap- 
pears untenable, although Prof. Thompson demonstrated 
such a division in the egg of a goose after five days’ in- 
cubation, which condition, if developed, would produce 
two united living creatures ; but we have no record to 
show that any segmentary division of a primitive single 
germ ever matured. The law might apply to some ot 
the lower orders of animal life in which, if a part be re- 
moved from a matured body, an exact analogue will be 
reproduced. 
This segregation does not pertain to mammals; it is 
true, the latter are, the viscera excepted, originally devel- 
oped in two lateral symmetrical halves, which ultimately 
unite to form the perfect being, but it seems entirely 
incredible, that the lateral halves of an originally single 
germ should, by mere excessive growth, develop two 
perfect individuals, joined only by some part of the osse- 
ous structure or soft tissue, when there is no power to 
reproduce a limb or an organ that has been removed by 
accident or disease. A legitimate reasoning from this 
hypothesis would lead us to expect ordinary, separate, 
perfectly twins, from a primary division of the 
nascent germ; for if the division could produce two united, 
there is no reason why an entire separation would not 
develop two separate foetuses, whether there existed 
either one or two umbilical cords. Were such a division 
the result merely of accident or excess of growth, we 
would, out of the great family of mammals, see more 4 
frequent departures from nature’s common laws, whereas 
this compound class or type are exceedingly rare in com- 
parison with the aggregate number of births. 
The limits of this article will not permit a relation of 
the minute classifications of monstrosities. It will be 
sufficient for our purpose to state, that the following case 
belongs to that tribe of compound monsters, which Geof- 
froy St. Hilaire calls autositaires—two individuals equally 
developed and having life in common. This tribe repre- 
sents two varieties, first, where the umbilicus is double; 
the union being effected at any portion of the trunk or 
head. To this class belong the black twin sisters of 
JSTorth Carolina, now living; the celebrated Hungarian 
sisters, who died at the age of twenty-two, and a few 
similar pairs; each pair being united by a lower part of 
the spine or sacrum. 
The second variety, representing those having one sin- 
gle or common umbilicus, are united by the soft parts 
of some portion of the abdominal or thoracic walls, or 
both. 
This latter mode of union is by far the most frequent 
and hence of greater professional interest, which is my 
apology for adding one more to the list already recorded 
For the privilege of presenting to the profession this 
interesting case of joined twins, I am indebted to my 
friend, Dr. E. C. Bright, of Eminence, Ky., who was 
kind enough to present them to me in the spring of 
1865. The Doctor informs me he was called to see the 
mother, a mulatto, aged twenty-eight years, in this, her 
third confinement, March 29th, 1865. The labor com- 
menced about 7 o’clock p. m., and terminated about 12 
o’clock, midnight; the entire labor embracing but five 
hours. The mother had no unusual symptoms, and was 
not unnaturally large during the pregnancy. The child- 
ren were living when labor commenced, but died before 5 
delivery was accomplished. He first saw the patient 
about 8 o’clock p. m. ; the head of the presenting foetus 
occupied the first position, and was, in a few minutes, de- 
livered ; it respired two or three times, when life ceased. 
No further progress being made, as is usual, at this stage, 
he made a thorough examination, and detected the pres- 
ence of twins. Still failing to effect further delivery, he 
called Dr. D. N. Porter, of Eminence, in council. By 
this time the uterine contractions had forced down the 
head and shoulders, sufficient to detect, by a digital ex- 
amination, the existence of a connecting hand. Traction, 
with forceps, was then made on the head of the present 
ing foetus, which force, with other manipulations, brought 
down the nates and feet; the time occupied about one 
hour. The second foetus, head also presenting in the 
first position, was delivered soon after without any man- 
ual aid. The single placenta, larger than common and 
having but a single umbilical cord, was removed at the 
usual time, and the mother rapidly convalesced without 
any after treatment. I have been unable to ascertain 
whether the mother has borne any children since. Dr. B. 
injected them, through the common carotid arteries, with 
a solution of the chloride of zinc and had a photograph 
taken, of which, plate No. 1, is an exact copy. Since 
they came in my possession, I have kept them in a solu- 
tion of the same material. At present they are well pre- 
served, without offensive odor, and all the tissues, organs 
and muscles are dissected with facility. Previous to mak- 
ing any dissections, a solid injection was thrown into the 
vessels through the common umbilical vein and common 
carotid arteries by Geo. J. Cook, M.D. 
The twins were born at full time, sex male, general 
physique, except at the bond of union, perfect, height of 
each nineteen inches; conjoined weight, 48 honrs after 6 
birtli, 18 pounds.* The connecting band extends from the 
zyphoid cartilages downwards 
to a point where the natural 
umbilicus should be; the skin 
is continuous on each surface 
with the corresponding abdom- 
inal walls, natural in appear- 
ance and without any trace of a 
median line or raphe between 
them. The band measures in 
its vertical diameter 4 inches ; 
transverse at the sternal border 
li inches, at the umbilical bor- 
der 2 inches; thickness through 
the lower half \ of an inch, up- 
per half 1 inch. There is but 
one common umbilical cord, 
which enters at the centre of 
the inferior border of the band, 
thus forming one single um- 
bilicus for two beings; it is na- 
tural in size and appearance, 
and is composed of one com- 
mon umbilical vein and four hypogastric arteries with 
the usual envelopes. 
Dissection. A vertical incision was made in the me- 
sian plane of the band, and transverse incisons at each 
border, dividing the skin and superficial fascia. The 
flaps being reflected, the zyphoid cartilages were found 
to connect in the centre, forming a section of an inverted 
arch between the twins, one half an inch in width and 
one line in thickness. A common linea alba, formed 
by the tendons right and left alternately of the broad ab- 
dominal muscles, extended from the junction of the car- 
tilages down to the point at which the umbilical cord 
entered ; here it bifurcated, one branch extending to the 
*Plate No.l.—Anterior view 
from a photograph, as they ap- 
peared after birth. R and L. 
Right and left loetus. a, con- 
necting band, b, superior or 
sternal margin. I, inferior or 
umbilical margin. U. common 
umbilical cord,entering the cen- 
tre of the lower margin at the 
common umbilicus C. 7 
symphysis pubis of each foetus. A linea alba similarly 
formed connected the left and right abdominal muscles 
in the posterior wall of the band. The recti muscles 
were next exposed, by dividing and reflecting the aponeu- 
roses forming their sheath. Each rectus muscle had two 
line* transvers*, and was perfect, except being a little 
longer than usual. A triangular flap, embracing the re- 
maining fascia and peritoneum, was then reflected down, 
which exposed a common cavity, three inches in its ver- 
tical diameter. The periton- 
eum formed one great continu- 
ous sac, which accommodated 
itself to the separate abdominal 
walls and viscera of each foetus, 
and a single liver common to 
both.* This viscus occupies 
an anomalous position; the 
greater part of the organ is 
suspended across the upper half 
of the cavity in the connecting 
band, the extremities termin- 
ating in the right hypo-chon- 
drium of each foetus. Its ver- 
tical diameter in the centre or 
mesian plane is one and a half 
inches; transverse diameter 
four inches, and thickness 
through the middle three 
fourths of an inch. It has two 
borders, two extremities and 
two surfaces. The posterior 
border is rounded, thick, slightly concave and attached 
to the under surface of the common diaphragm by one 
continuous reflexion of the peritoneum. The anterior 
border is sharp, irregular and pointed or nodulated a. 
the centre of the band. The ends terminate in tongue- 
*Plate No.2—Kepresents the 
common abdominal walls, di- 
vided and reflected to show the 
position of the superficial vis- 
cera; F F, the flaps, L, com- 
mon liver; u, umbilical vein ; i, 
small intestines; S, right stom- 
ach inflated; o, part of left great 
omentum and colon inflated; 
D, diapiiragm ; li h, the two 
hypogastric arteries of each foe- 
tus; b, left bladder and the ura- 
chus projecting lrom its apex. 8 
like processes, each one occupying the position of the 
great lobe of the liver in the natural order of develop- 
ment. The right end, measured from the median line, is 
longer and more slender than the left; but about one hall 
of the cubic dimensions of the organ lie on each side oi 
this line. The upper surface is free, smooth and covered 
with peritoneum. The under surface is irregular; in the 
mesian plane is a central depression or fissure occupied 
by the common umbilical vein, which is attached to the 
liver by a reflection of the peritoneum that represents the 
suspensory ligament. On either side are irregular eleva- 
tions which may be termed the analogues of the quadri- 
lateral lobes. External to these on each side is a fissure 
occupied by the gall bladder.* Further removed from 
the central line, we have reflected from the under-sur- 
face two gastro-liepatic omenta which connect with the 
small curvatures of the two stomachs. Between the 
folds of the omenta, we find, for each foetus, the usual 
vessels, viz: vena-porta, hepatic artery, hepatic duct, 
nerves and lymphatics, entering into or emerging from 
*Plate No. 3—Represents the liver reflected upwards to show the 
under-surfsce, with sections exhibiting the principle branches and 
common distribution of the umbilical vein. R, right, L, left extremi- 
ty ; S, section showing brandies of the umbilical vein ; b b, divisions 
of the vein springing from the common trunk U; g g, the gall blad- 
ders; e e, hepatic ducts joining the cystic ducts to form c c, the ductus 
communis choledichus of each side ; d d, vertical portion of the duo- 
denuins showing the terminus of the biliary ducts ; v, the vena portie 
of the right ride entering the portal fissure; h, hepatic artery of right 
side; O, the stomach of the left foetus inflated. 9 
imperfectly developed fissures. In the left foetus, the as- 
cending cava passes the under-surface near its narrow 
terminus, (plate 1) where it is joined by the ductus ve- 
nosus and hepatic veins. In the right foetus, the ascend- 
ing cava makes a curve from the right to the left of the 
vertebral column (plate 4) and is joined by the ductus 
veuosus and hepatic veins as it passes the posterior border 
to perforate the diaphragm on the left of the spine and 
connect with the right auricle. The parenchymatous 
structure is analogous to other livers, with this difference: 
that in this common organ we find no trace of any sep- 
tum denoting an original development in two parts, and 
we have two sets of hepatic vessels having a promiscuous 
distribution from which common reservoir they distribute 
to two distinct individuals. In utero they were supplied 
with maternal blood through one common channel, the 
umbilical vein ; and nourished and developed from one 
common source, the placental blood, which flowed 
through one common organ before general distribution. 
We have, in this abnormal development, an irregular 
substance suspended in the septum, carrying the life- 
blood of two human beings. It is covered by perito- 
neum ; the vertical line of its under-surface is occupied 
by the trunk of the umbilical vein; on either side two 
gall bladders, two cystic ducts, two hepatic ducts; further 
removed from the common mesian plane, and nigher the 
centre of the under-surface, two shallow fissures, each 
giving exit to biliary ducts and deep lymphatics distrib- 
uted to two separate alimentary canals and thoracic ducts, 
each transmitting a hepatic artery, vena portse and hepa- 
tic nerves to nourish, support and feed a chemical labora- 
tory, which distributes alike its invigorating or baneful 
fluids to two living beings. In the interior we find, first, 
the distribution of the umbilical vein represented in plate 
No. 3 at u and b b; second, we find in the lobules the 10 
terminal capillaries of the hepatic arteries, hepatic ducts, 
lymphatics and nervous twigs, and the commencing radi- 
cles of the hepatic veins, which are ultimately developed 
into two hepatic systems, each of which converges to- 
ward and connects with the respective inferior cavas as 
seen in plate No. 4 at h h, 11, N and 0.* 
The office of this liver might be compared to that of a 
filter, placed in a recess common to two households, and 
from either extremity pouring out to the occupants a con- 
stant stream of pure invigorating fluid or distributing 
the germs of sickness and death. 
The anatomical peculiarities are briefly summed up as 
follows: 1. The junction of the zyphoid cartilages; 2, 
two linea albas; 3, one common diaphragm; 4, one com- 
mon peritoneum lining a common cavity and two sets of 
*PijATE No. 4.—Upper surface of the liver showing the common dis- 
tribution of two distinct hepatic veins; R, right, L, left and, c c, cen- 
tre of tho upper surface ; h h, branches of the hepatic veins converging 
and coalescing toward either extremity; 11, trunks of the hepatic veins; 
v, right vena cava ascendens; N, the common venous trunk of the 
right foetus; a, left vena cava ascendens uniting with the left hepatic 
veins to form the common trunk O ; s, small section of liver detached to 
show hepatic veins at i; u. umbilical vein ; y y, ductus venosus of 
each side; M, common diaphragm showing the openings for the cavas 
N and O. Hail 8r Map other T.iUi from Pholnjirapb liy Klaiihf.r ft -vll !,» imviIIc, Ky 11 
viscera, with one exception; 5, one common umbilical 
vein ; 6, one liver, with a double circulation ; 7, the curve 
of the inferior cava of the right foetus to the left side of 
the vertebral column; 8, the radical change in the rela- 
tions of the vena cavas, hepatic veins and venous ducts 
to the posterior border of the liver; 9, the duplication of 
all the organs (liver excepted) as represented in plate 5.* 
The physiological questions may he very briefly con- 
sidered in two relations: flrst, through the common liver 
and, second, through the connecting soft tissues. In the 
liver terminate the peripheral extremities of a portion of 
the two great nervous systems; the cerebro-spinal axes, 
connecting its animal sympathies with the cerebrums 
through some filaments derived from the pneumogastric 
and right phrenic nerves. The ganglionic systems con- 
necting intimately and inseparably, the organic functions 
through the hepatic plexuses derived from the solar 
plexuses of two beings. We have in the nerves, a union 
of sympathy and organic function. The complicated 
*Plate No. 5.—R, right, L, left foetus; C, common liver; E E, 
right and left extremities of the liver; U, umbilical vein ; D, com- 
mon diaphragm; S, stomach and duodenum; v v, inferior or 
ascending vense cavse; m, superior mesenteric vein entering the 
under-surface of the right extremity of the liver ; S'. spleen : a, splenic 
artery ; x, splenic vein ; y, superior mesenteric artery distributed to a 
portion of jejunum j ; k k, kidneys, the right kidney of the left foetus 
having the capsule removed to show the lobulated structure, renal 
artery and vein, and the left kidney surmounted by the supra renal 
capsule; i i, common iliac arteries diverging from abdominal aortas, 
also showing the four hypogastric arteries tied to the end of the cordU ; 
u', ureters of the left foetus; B B, the bladders, showing in each the 
urachus projecting from the apex ; t, gubernaculum testis ; F, sigmoid 
flexure of the colon inflated and turned back; H, heart of the left 
foetus, on either side of which the lungs are seen; P, pulmonary ar- 
tery; A, aorta with ductus arteriosus concealed; O, superior or de- 
scending cava formed by the union of the right and left venae innomi- 
natse seen above; they again eadh formed above by the internal jug- 
ular and subclavian veins ; e, common carbtid arteries of the left foe- 
tus ; n n, right and left pneumogastric nerves ; w, trachea ; IF, heart 
of the right foetus enveloped in its pericardium, the latter attached to 
the diaphragm; the lungs are shown on either side ; O', superior or 
descending cava of the right foetus, formed by the junction of the 
brachio-cephalic veins; I, arteria innominata dividing into the right 
common carotid and subclavian arteries; 1, left subclavian vein; 1', 
left internal jugular vein; T, thymus gland; r, thyroid body; z, 
larynx. 12 
structure of the organ fits it for its great function, the 
distillation of the bile, a constant secretion in greater or 
less quantities; and constantly delivered from this com- 
mon source to two digestive apparatuses. 
This fluid, complex in its chemical composition, is not 
a mere excretion as some maintain; but it is a necessity 
to nutrition and life, as proved by experiments on dogs 
in which death soon followed the absence of bile in the 
intestinal canal. Two lymphatic systems also act their 
part in the hidden mysteries which govern the laws of 
health. In short, this single organ performs all the im- 
portant physiological functions connected with the liver 
for two individuals. 
The physiological union through the soft tissues of the 
connecting band are of minor importance, being limited 
to the capillary inosculations of the sanguineous and 
lymphatic systems, and the intermingling of the sensor 
and motor nerves for a short distance on either side of 
median line. The healthy relations of the two then are 
common, derived from the same fountain head and dis- 
turbed by the same causes. 
In their pathological relations any symptomatic, disease 
of the liver, whether functional or organic, would necessa- 
rily aflect both alike. Functional disorders of any of 
the duplicated organs, as the brain, lungs, heart, etc., of 
one .would not disturb necessarily the health of the other 
twin. Local inflammations in one, as pneumonia, ne- 
phritis, dysentery, &c., would not be developed in the 
corresponding organs of the other, but he would only 
suffer from the symptomatic fever communicated through 
the circulation. Idiopathic disease, as typhoid fever, and 
zymotic disease, as small-pox, rubeola, poison, &c., would 
aflect both simultaneously through the vascular and 
lymphatic connections. The administration of all reme- 
dies, acting through the systemic circulation, would influ- 13 
ence both alike in consequence of tlie two capillary anas- 
tomoses—first, and most important, in the liver, and, 
second, in the connecting band. 
The Obstetrical Relations.—The frequency with which 
monster births have occurred in all ages and all coun- 
tries, as evinced by the number of cases found in medical 
museums, private offices, and reported in the medical 
journals every year, attaches great and special importance 
to this part of the subject. These births are not prema- 
ture, as is generally supposed; but they come at full 
term like ordinary confinements, without any premoni- 
tion of the complication. In the following reported 
cases, only one was said to be premature and this one 
only twenty days before the time. Such a birth may 
occur under the supervision of any practitioner, the 
proper obstetric management of which, in many in- 
stances, involves the life and future health of the mother 
and the life of the two unfortunate twins. In this em- 
barrassing perplexity the impulse of the moment is not 
always a correct index to the proper treatment necessary 
to be instituted. One rash, inconsiderate step will jeop- 
ardise the life of three human beings. The hopes of the 
mother and friends are concentrated in the adjudged 
superior skill and wisdom of the attendant physician. 
What landmarks, then, have we from past experience ? 
W. S. Playfair, M.D., selects from Dr. Allan Thomp- 
son’s classes four varieties which interest the obstetri- 
cian :* 
First. Two nearly separate bodies united in front to a 
varying extent by the thorax or abdomen. 
Second. Two nearly separate bodies united back to 
back by the sacrum and lower part of the spinal col- 
umn. 
♦See Obstetrical Transactions, VIII. 14 
Third. Dicephalous monsters, the bodies being single 
below but the beads separate. 
Fourth. Bodies separate below, but the beads fixed or 
partially united. 
Dr. Playfair has collected 31 cases belonging to these 
four classes, which present the following ratio of fre- 
quency : First class, 19; second class, 3; third class, 7; 
fourth class, 2. It will be observed, as a point of profes- 
sional interest, that a fraction over three-fifths of the 
whole number belong to the first class. 
Of the thirty-one births, twelve were delivered by na- 
tural powers and without difficulty. How fortunate that 
nature is so provident and sumptuous in her resources, to 
overcome obstacles. 
In the nineteen cases belonging to the first class, to 
which, also, belongs the pair presented in this paper, and 
the Siamese twins now living, of whose birth no account 
has ever been given, the labors resulted as follows : “One 
(mother) died undelivered; eight were terminated by 
natural powers, in three of which the feet and in three 
the head presented ; in two the presentation is doubtful; 
six were delivered by turning, or by traction on the lower 
extremities; four were delivered instrumentally.” 
In the three feet presentations, delivered by natural 
powers, the best account is given by Fanzango, of joined 
twins, born alive at Camignore, November 6, 1602, who 
lived a number of years and were exhibited in Italy. The 
bodies were only united by the upper part of the abdomi- 
nal walls. Fanzango remarks:* “It was a happy cir- 
cumstance for the mother that she was not under the 
charge of a practitioner with his head full of the doe- 
trines of the surgeons on this subject, otherwise he pro- 
bably would have performed some severe and dangerous 
*See Obstetrical Transactions, "VIII. 15 
operation, mutilating the children, with the view of aid- 
ing delivery.” The same remark is apropos to the sur- 
geons and physicians of the present day, who think the 
Siamese twins have committed a great sin by remaining, 
as nature formed them, united. 
In the cases of version terminating favorably, the 
mechanism of the labors was the same as in feet present- 
ations. The best account of delivery, by version, is 
given by Drs. Brie and Molas, each relating a case in his 
own practice. Dr. Brie called to see a patient under the 
charge of a midwife, found two feet belonging to two 
different children presenting. lie replaced one foot and 
brought down one corresponding to that already born, 
made traction and delivered the lower half of the child; 
the connecting band prevented further progress. lie 
then recognized the mode of connection, introduced the 
hand, brought down the feet of the second child, and by 
continued traction delivered both simultaneously as far 
as the heads; at this juncture all progress was arrested 
and further pulling only increased the difficulty. He 
then made traction “by turning the bodies of the chil- 
dren over the abdomen of the mother, the posterior head 
became engaged in the pelvis and after it was delivered 
the second easily followed.” 
Dr. Molas’ case occurred in a healthy multipara, aged 
thirty-two years. The labor commenced at 7 p. m., Aug- 
ust 15, 1822; 6 o’clock a. m, next morning, the os uteri 
being fully dilated, the membranes were ruptured. The 
two heads presented at the brim of the pelvis at the 
same time; he tried to push one aside to allow the other 
to descend ; no further progress being made in one hour 
of strong pains, he desisted. lie suspected joined twins 
and determined to turn: he introduced his hand, found 
the children united by the thorax and brought down the 
feet of both. “The bodies were delivered with ease and 16 
tlie arms came down of themselves, but considerable dif- 
ficulty was experienced in extricating the heads, which 
was only effected by pulling the bodies of the children 
well over the abdomen of the mother, so as to get the 
posterior head to engage first in the pelvis.” 
In three cases—the labor conducted by natural powers 
—the head remained the presenting part; the trunk, 
nates and feet followed by evolution; then usually follow 
the feet of the second child. In some, the head of the 
second child presents after the body of the first child is 
delivered, as in Dr. Bright’s case, which was skillfully 
managed. In other instances, the two heads are born 
first, one immediately after the other, and the two bodies 
pass the straits of the pelvis simultaneously. When this 
occurs the head of the hindmost fits into the depression 
formed by the neck of the first child ; to do this requires 
a wide and well-formed pelvis. 
In the second class—united back to back—the labors 
terminated without manual assistance. In the two de- 
scribed, the head presented first. 
One case is that of Helene and Judith, who lived about 
twenty-three years. “Helene was born as far as the um- 
bilicus, and after the lapse of three hours, her breech 
and legs descended. Judith was expelled immediately 
afterwards, her feet descending first.” The same mode 
of delivery accompanied a case related by M. Norman; 
the children were born alive and survived nine days. 
This class is more easily delivered than the first, in con- 
sequence of the union at the lower part of the trunk, al- 
lowing more latitude of motion and permitting the 
breech and lower extremities of the first to pass readily 
by evolution. 
In the third class—diceplialous monsters—two of the 
seven cases were delivered by nature’s powers ; one head 
first presenting, then the body and next the second head. 17 
In the only two cases related, belonging to the fourth 
class, the head was perforated in one and version resorted 
to in the other. It is remarkable, that in all these re- 
ported cases, the mothers, with one exception, made good 
recoveries. 
The management of the labor in all the classes may be 
best studied from the following rules laid down by Dr. 
Playfair, in the summary of his excellent article: 
1. Of the various classes of monstrous twins, those in 
which the bodies are joined by the sternum or abdomen 
are much the most common. 
2. The most favorable presentation is undoubtably 
that of the lower extremities; and if the head present, 
and the nature of the monstrosity can be recognized, 
turning should be resorted to, and the feet of both chil- 
dren brought down to the pelvis. 
3. The bodies can generally be extracted without 
much difficulty by direct traction, until the shoulders have 
passed. In doing this, the backs of the foetuses should 
be placed in one of the oblique diameters of the pelvis. 
4. The bodies should then be turned well over the ab- 
domen of the mother, so as to cause the posterior head 
to pass first into the cavity of the pelvis. If this cannot 
be effected, the anterior body must be amputated, when 
the other will probably pass without difficulty. 
5. If the head presents, the body corresponding to the 
tirst-born head may be expelled by a process similar to 
that of spontaneous evolution, or the second head may 
be expelled with its occiput fitting into the cavity formed 
by the neck of the first child. Failing in either of these 
terminations, mutilation of the foetuses will be required. 
6. In class two, in which the children are joined back 
to back, the mechanism of delivery is essentially the 
same as in class one, whether the head or feet present* 
But evolution of the body of the first-born child, in head 
presentations, is probably accomplished with greater ease. 
7. In class three, after the birth of the first head, the 
body must be expelled by evolution. If this is not ac- 
complished, it will be advisable to decapitate the first- 
born head, and to terminate the labor by bringing down 
the feet of the child. 
8. In class four, when either the head or feet present, 18 
if the head causes obstruction, it must be lessened by 
perforation, when, in all probability, there will not be 
much difficulty experienced in effecting the birth of the 
bodies. 
No record of the number of these thirty-one cases of 
twins born alive is given. The great majority die during 
delivery, from continued pressure on the umbilical cord, 
occasioned by the delay in delivering the first body, 
where they are born one at a time; or, by the delay in 
the passage of the two heads through the pelvic straits, 
where the feet present either naturally or by version. 
It is highly probable, if the rules, already quoted, are 
promptly carried out, the mortality in future will be very 
much diminished. 
The great surgical question to be decided is the pro- 
priety of an operation to sever the bond of union. Is it 
justifiable ? Will its results terminate favorably to the 
lives of both? Are we, in the premises, warranted in 
jeopardizing the lives of two individuals, for the purpose 
of adding to their personal comfort and convenience, and, 
we may add, our own fame? 
The rational solution of these questions depends on the 
nature of the attachments. When a dwarf, miniature or 
blighted fcetus is attached to the superficial soft parts of 
some portion of a healthy, well-developed child, viz : the 
cheek, as in Prof. Pancoast’s case, an operation would be 
highly proper with every reasonable hope of success. 
But where the attachments involve any considerable por- 
tion of the abdominal or thoracic walls, an operation un- 
der any circumstances, when the twins are in good health, 
is questionable; nor do previous results justify its per- 
formance. 
In order to indicate some of the insuperable anatomi- 
cal objections, we will refer to some of the abnormalities 
of visceral conformation recorded in some few instances 19 
at my command, where dissections were made. First 
case, reported by T. II. Tanner, M.D.* Sex, female ; still- 
born at the eighth month. The attachment extended 
from the top of the thorax down to where the natural 
umbilicus should be. The thoracic cavity was common, 
containing two lungs, one heart and one sternum. The 
abdominal cavity was common, ‘‘having one liver, one 
spleen, two kidneys and one set of intestines,” one single 
cord and placenta. Second case, reported by J. G. 
Swayne, M.D.f Sex, male. The union extended from 
the umbilicus to the top of the thorax. There was one 
sternum and tour clavicles, one thoracic cavity with a 
pericardium, containing two separate perfect hearts, one 
venous connection through a large branch connecting the 
right vena innominata of one foetus with the left vena 
innominata of the other. In the abdomen there was a 
single diaphragm, one common liver, one umbilical cord 
having one vein and four arteries. All the other organs 
in both cavities were duplicated. 
Third case, by W. Wills, Sex, male; children 
were well developed and connected from the upper part 
of the thorax down to the umbilicus. Umbilical cord 
double and in one sheath entered the cavity between the 
foetuses ; one large single liver, one gall bladder with two 
biliary ducts and one large spleen. The intestinal canals 
and all other abdominal and thoracic viscera were double 
and perfect. 
It may be argued that the connection in these instances 
was too extensive, and, therefore, they are not analogous 
cases and do not militate against an operation where the 
attachment is limited to the ensiform cartilages and ab- 
dominal walls. The thoracic attachments have nothing 
♦See Obstetrical Transactions, Yol. II. 
fSee Obstetrical Transactions, Yol. II. 
JSee Obstetrical Transactions, Yol. VII. 20 
to clo with the question, these cavities are separate and 
distinct from the abdomen. Had the bond of union been 
limited to the latter, the same malformation would have 
existed, viz: in each instance one or more of the vital 
organs single and common to both. Who then can de- 
termine beforehand, with certainty, that a similar or some 
other malformation does not exist, where a similar union 
of soft parts obtains? 
In the case reported by myself, there was nothing in a 
superficial examination to indicate the presence of a liver 
in the band. The upper half of the band was thicker 
than the lower, somewhat soft and spongy to the touch, 
feeling more like thickened cellular tissue, with the ensi- 
form cartilages prolonged through the upper margin, 
than an organ. There were no arteries of sufficient size 
to give any considerable impulse when compressed. Had 
they lived and grown up, it is reasonable to suppose, that 
the wearing of boys apparel, would have diminished the 
width of the band, and that the pressure on the surfaces 
would have gradually changed the shape of the liver, by 
lessening the size in the central portion and enlarging the 
two extremities. Ho organ in the body i3 so amenable, 
without injury to its structure and function, to a change of 
form, either from external or internal pressure. Constant 
tight lacing will entirely alter the shape and even the 
natural position of the liver. Cruveilhier, in his anatomy, 
says of the liver: “It may even be said to be, as it were, 
ductile or maleable under the influence of slowly exerted 
pressure.” Speaking of tight lacing, he says : “A circu- 
lar constriction and a fibrous thickening of this organ 
opposite the base of the thorax, sometimes affords evi- 
dence of this compression ; its transverse and antero- 
posterior diameters become diminished, and its vertical 
diameter increased; it projects more or less below the 
base of the thorax, descends as low down as the right 21 
iliac fossa and may even touch the brim of the pelvis 
without any structural lesion.” 
A similar change of form in the liver is likely to occur 
in living twins joined by the abdominal walls. A com- 
mon liver, however, in the centre of the band is not uni- 
form ; other conformations are found. In one case, out 
of the one hundred and fourteen reported of this partic- 
ular connection, viz : an umbilical cord with one envelope, 
the band was divided, six arteries and one vein were tied 
on either side of the mesian line on which the incision 
was made. The success of the operation may be in- 
ferred from the report of the case given in the latter part 
of this article. 
An important surgical question of the present day is the 
propriety of dividing the band connecting the celebrated 
Siamese twins, the only known pair now living, of this 
kind of union. No occasion has ever ottered to enable 
me either to see or examine these twins. The proper 
solution of the question will be decided by the analogies 
between them and other similar attachments and the 
results of previous operations. Some distinguished pro- 
fessional gentlemen maintain that they ought to have 
been separated long ago; first, from the fact that their 
nervous physiological relations are distinct, and, second, 
that the bond of union is only cartilaginous. The 
mere discovery, by touch, that common sensation only 
exists at the centre and for about one inch on either 
side of the middle of the band proves nothing; tor here 
we have only the terminal branches of the sensitive 
nerves of two distinct nervous systems, and this phe- 
nomenon is only what any one versed in anatomy and 
physiology would expect to find. The existence of 
two separate brains, spinal cords, and nerve branches, 
in this form of attachment, would naturally develop, 
in the twins, ditterent dispositions, temperaments, in- 22 
tellects and physiognomies; the same as in disconnected 
persons. While the vascular and lymphatic inoscula- 
tions in the band would establish a common sympa- 
thy, when either suffered from any disease develop- 
ing constitutional symptoms. There is not the same 
reason to look for common sensation in both from touch- 
ing one twin, as we would expect in our own person 
having but one nervous system, to feel the sensation of 
an injury in the left foot, which was inflicted on the 
right. A single brain and nervous attachments are capa- 
ble of executing different feats at the same time. Ex- 
ample : the musician singing in one key and playing in 
two different keys at the same time. (Why not expect 
two different brains to do the same ?) 
In regard to the analogies of conformation, Mr. Holmes, 
(Surgical Treatment of the Diseases of Children) says of 
the Siamese twins, “the band which united them stretched 
downwards from the ensiform cartilage. It measured 
three and one-fourth inches in the vertical direction, one 
and five-eighths inches at its thickest part from before 
backwards, and it was one and three-fourths inches long 
at its upper and three inches at its lower edge. The 
ensiform cartilages of the two bodies meet in this band 
and seemed to be united by a kind of joint. A hernia 
projected into the band from the body of each of the 
twins.” Prof. J. C. Warren, M.D., (Silliman’s Journal, 
1830,) who saw them when they were eighteen years old, 
describes the band as follows: “The substance by which 
they are connected, is a mass two inches long at its upper 
edge, and about five at the lower. Its breadth from above 
downwards, may be four inches; and its thickness in a 
horizontal direction, two inches.” “At its lower edge is 
a single umbilicus, through which passed a single um< 
bilical dord, to nourish both children in the foetal state.” 
He found this band extremely hard to the touch. It was 23 
found, on a more minute examination, that the hardness 
existed only at the upper part of the hand and was “pro- 
longed into the breast.” This substance was formed by 
a continuation of the ensiform cartilage, or lower extrem- 
ity of the breastbone, from one to the other; its breadth 
was one and a half inches; its thickness about one eighth 
of an inch. These projecting cartilages met at an angle 
in the centre, connected by a ligament which formed a 
joint. Below the cartilage was felt a rounded cord which 
Dr. Warren supposed to be the fibrous remains of the 
umbilical cord. The analogies here, between the external 
appearance and measurements, and other cases given in 
the text, are striking. From what Dr. Holmes says, we 
would infer, that in early life, a free communication ex- 
isted between the abdominal cavities; from the irritation 
excited by pressure and pulling, the peritoneal surfaces 
may have adhered or grown together and closed the 
common canal through the band. 
Such adhesions do occur in this way, and why not 
here. If it has, it would enhance the probabilities of 
success in an operation. A double cord in one en- 
velope may have existed, as in case third, referred to 
above; or the cord may have been single as in the other 
cases, and coursed through the band which had in it 
neither a common communication nor a vital organ, as in 
Dr. Boehm’s case mentioned below. The true relations 
can only be determined by actual dissection. What have 
been the results of operations in this form of union? 
Dr. Holmes* says: “As to joined twins, one successful 
operation for their separation is on record by Konig.” 
“The band is described as stretching from the ensiforni 
cartilage to the umbilicus, and being an inch broad, one 
and a half deep and five inches long.” The umbilical 
Treatment of the Diseases of Children. 24 
cord was single and contained four arteries and two veins. 
It will be noticed there was in this case a double cord in 
one envelope, as in case third, cited above. Dr. Holmes 
further says: “Its lower part was attached to the band 
and it seems doubtful whether the band was really anything 
more than a fusion of the two cords.” “A ligature was 
put upon it first and then divided by the knife.” “In the 
only other case which I have met with, in which the sep- 
aration of joined twins was attempted, the result was 
fatal”* 
The New York Medical Journal for December, 1868, 
gives the report of the following case operated upon, 
taken from the “ltevue deTherapeuticpie Medico-Chirur- 
gicale, of August 1.” 
Dr. Boehm has successfully performed the operation of 
separation of twins that were adherent to each other by 
a fleshy band. 
The junction between the two children (females), who 
were very small, but in other respects well developed, 
commenced at the inferior extremity of the stern urns, 
which were entirely distinct or separated, and following 
over the xiphoid cartilage, terminated in a single or com- 
mon umbilicus. This connecting band was soft to the 
touch, not unlike a thick cushion of cellular tissue; but 
there could be felt, as it were, some hard and knotty 
cords, which later, on dissection, were found to be formed 
by the cartilaginous branchings which, starting from the 
two xiphoid appendages, joined together the middle of 
the band, in order to form a cord, by the side of which 
coursed the vessels of the umbilical cord. The operation 
commenced by dissecting up and isolating the vessels of 
the umbilical cord, which was single and had one envel- 
ope, a single sheath closing in all the vessels. This 
sheath was divided by a bistoury, and the vessels were 
dissected up three or four inches from the umbilicus. In 
this w~ay six arteries and one vein were dissected out on 
each side and were ligated separately. After this the 
operator made an incision upon the band, parallel to the 
surfaces of the thorax, and taking care always to keep in 
*In theYatal case the union was in the coccygeal region. 25 
the median line, cut more deeply into the cellular tissue, 
divided the union ot the cartilaginous appendages, and, 
passing between the two points of insertion of the um- 
bilical vessels, arrived finally at the skin on the opposite 
side, when a single stroke of the knife finished the opera- 
tion. Very little blood was lost. The two flaps had a 
length of five and a half centimetres and were united at 
three points by suture. Union took place by the first 
intention; but one of the infants, which, from birth, had 
shown less strength and vitality than the other, died on 
the fifth day. The other is now living, at the age of five 
years ; is in perfect health and well developed, except 
that there is a separation six centimetres in length in the 
linea alba below the xiphoid appendange. 
According to the statistical researches of Foerster, out 
of one hundred and fourteen similar and collected cases, 
this is only the second, where a successful result has fol- 
lowed the operation of separation.” 
The result here is certainly a strange kind of success 
to claim ; the band was severed and the feeble child died 
in five days—the death to be fairly attributable to the 
operation and nothing else, and an opening, over two 
nches in length, through the abdominal walls of the liv- 
ing child. So far as regards the mechanical part, it was a 
success, as much so as when a butcher, with usual dexterity 
in the use of the knife, severs the jugulars of an animal. 
As to the results, the operation was a failure. Had they 
been let alone, the blood from the healthy child would 
have aided in sustaining the feeble one, with the same 
happy results that follow transfusion of blood from the 
vein of a healthy person into the veins of a patient ex- 
hausted from loss of blood or by disease. 
The mere dissection of one of these bands is much less 
difficult and requires less skill than the removal of a 
tumor from the anterior region of the neck; hence the 
division is no surgical feat. 
The object of an operation is either to remove or re- 
lease a diseased part, in order to save and prolong life; 
or to remedy a deformity natural or acquired. To the 26 
former belong operations of necessity, where the aims 
justify the means, whether the patient survives or dies; 
as, for example, amputations, strangulated hernia, &c. 
To the latter belong operations of choice, where the 
patients, or their representatives, in cases of minors, 
solicit an operation. Example: in contracted tendons, 
moles, supernumerary toes, fingers, cleft palate, &c. It 
is but seldom had results to life follow such, and, there- 
fore, they are justifiable. 
But where the results have been almost, we might say, 
universally fatal, as in joined twins, no operation should 
be hazarded by the advice of the surgeon, unless one 
should die before the other; then it becomes a necessity. 
If the twins, knowing all the risks, demand a division 
of the bond, a surgeon might, under protest, execute the 
mechanical part, they relieving him of all responsibility. 
The success would be an accident, not skill. If one or 
both died, he could console himself with the thought 
that he acted in obedience to their commands and not his 
judgment. 
The Siamese twins have been severely censured for vio- 
lations of the moral and social relations of life; these 
strictures being based upon the supposed simplicity of 
their bond of union. What have they to hope for in an 
operation, when no one case, coming properly under 
their particular mode of junction, has been successful ? 
In the only case of success, the band was only one inch 
in breadth, had two umbilical cords in one sheath, and, 
as Dr. Holmes remarks, was probably only a fusion of 
the cords. The preservation of life is an inherent prin- 
ciple, and, in view of all the facts, the Siamese Twins 
have acted with discretion and much wisdom. As to 
the moral question, we have only to say to the moralists: 
first renovate society at home of all the social evils, before 
going into Horth Carolina to hunt up the unfortunate 
Siamese twins, against whom to hurl anathemas.