MONSTROSITIES. 425 



Diagnosis. 



The diagnosis of these monstrosities is often very difficult, as they may 

 be mistaken for ordinary twins. Franck has drawn attention to the circum- 

 stance that there is very frequently a difference in the presentation of the 

 ■ merely double-headed foetus and the double fcetus, particularly the double 

 croup ; the first being mostly in the anterior presentation, the latter in the 

 posterior. 



In the case of the double fcetus, its presence may be suspected when 

 one cannot be moved without also moving the other ; when one is brought 

 into a good position with regard to passing through the pelvic inlet, and 

 it cannot be advanced beyond a certain point, though the passage ap- 

 pears to be sufficiently wide to permit easy delivery, because the other 

 lies across the inlet ; when the hand is passed between the two foetuses 

 and is stopped at the point where the skin is carried between them at 

 their junction ; and when they are united by homologous parts, as already 

 explained. With regard to the latter, as Saint-Cyr points out, we may 

 be positive. If, for instance, two foetuses lie together at the inlet in the 

 same presentation — anterior or posterior — there is nothing to be inferred 

 from this as to their being monstrosities or merely twins, as the presen- 

 tation may be the same for these latter ; but if one is in the anterior, the 

 other in the posterior presentation, then we may be certain that they are 

 7iot united. Heterologous parts do not unite. 



The diagnosis in the case of Monocephalian monstrosities is compara- 

 tively easy when the head presents. But much care and attention are 

 necessary in forming a diagnosis in such cases, and the examination of 

 the bodies should lead, if possible, to an exact notion of their condition. 



Extraction. 



In some cases, though they are very rare, extraction may be possible 

 by manipulation and judicious traction ; but, as a rule, embryotomy, or 

 even the Cesarean section, has to be practised. If it were possible to 

 separate the two individuals by excising the parts which unite them, then 

 birth would probably be as easy as with twins ; but it can rarely be prac- 

 ticable, for the simple reason that the point of union is generally beyond 

 reach : it is too extensive to be cut through, or the junction is of an os- 

 seous character. Nevertheless, cases may occur in which the knife and 

 the obstetrical saw or bone forceps may be most effectively employed in 

 accomplishing disunion. 



When the monstrosity is in the anterior presentation, should it prove 

 to be double-headed, then it will be found advisable to remove one of 

 the heads as low down the neck as possible ; after this is done, removal 

 of two or more of the anterior limbs, by subcutaneous section, will often 

 diminish the diameter of the body to such an extent that traction on the 

 head and remaining skin of the limbs will sometimes effect delivery. If 

 not, then eventration of the thorax and abdomen will be necessary. 

 When the two croups cannot be made to pass through the pelvis togeth- 

 er, it will be imperative to divide each across, as far back as possible, 

 extract the anterior halves, push the posterior into the uterus, turn them, 

 and deliver them as in the posterior presentation. Sometimes excision 

 of one or more of the hind limbs, in order to diminish the volume of the 

 double croup, will be necessary before the operation can be completed. 



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