REPORT OF A CASE OF TWINS OF UNEQUAL

SIZE AND AGE.

BY W. W. EVANS, M.D., HIGGSTON.

Our first general impression of a twin labor as regards the results is equality in size and similarity in appearance; then we think of the cases we may have seen in which disparity in every respect is notable, but the mention of twins of unequal age will perhaps produce a feeling of the apostolic Thomas.

That twins are very frequently of unequal size is patent to every obstetrician, but that two products of the same parturition are of several months different age is not a generally conceded fact.

While some cases are reported in medical literature upon the hypothesis of superfetation, some writers of note deny the hypothesis and explain the difference in size on the grounds of disparity of development. Lusk says: "That impregnation can take place at two periods distant from one another must be regarded as an inadmissible hypothesis." But we will give the facts of the case with a few observations.

On March 7th, I was called to Susie B, a mulatto woman nearly 35 years old; strong, healthy and had neverhad any special difficulties in her seven previous confinements. Upon reaching and examining the patient I remarked that the position was such as to make a difficult labor and that the uterus was large enough for twins or a twelve-pounder. Manual examination revealed a left-oc

cipito transverse position, dorso-anterior presentation. Quick work did not insure a successful attempt to produce version, as labor was progressing rapidly and the right arm presented at and through the os uteri under the forcible contractions. Being unable to produce version I awaited the aid of nature a while, meantime sending for my assistant to administer chloroform. There being no progress or change of position we anesthetized and in a few minutes produced version by combined manipulation, pushing the arm back and the breech up so that the head presented R. O. A. position. I soon applied forceps and very easily accomplished delivery.

After turning patient back straight in bed and tying off cord, a second fetus appeared having its cord of jelly-fish consistency. Delivering the placenta of regular size, a little flattened on one edge, I found another about an inch and a half in diameter, with distinct sacs.

The first child was normal in every respect, weighed seven and one quarter pounds-about her previous average -and is now at about an average stage of development for a seven weeks' child; the second weighed six ounces, was between nine and ten inches long and about what you might see in a four months' fetus. I firmly believe it had been alive previous to the labor and perhaps might have remained in situ to full term but for the forcible internal manipulations necessary to perform version and delivery of the first, the hand having been introduced to push the breech up and to the right side where I suspect the small placental attachments existed. We may presume, with a vertex presentation requiring nothing but the passive watchfulness or "Gunpowder Tea of Granny," fetus number two would have gone on to maturity and been born, perhaps, five months' later; as Playbair, pp. 164-5, illustrates with a case reported by Dr. Bonnar: "A child was born September 12, 1849, and the mother gave birth to another on Janu

ary 24, 1850, after an interval of only one hundred and twenty-seven days. Both these children survived.”

It might be held in discussion of the case now reported that both were conceived from a single coitus and the development was unequal. King says: "The growth of the embryos in twin cases is seldom exactly equal and sometimes the difference is very great, one child appearing fully developed while the other remains very small. One fetus may die and be thrown off prematurely while the other remains to full term. Occasionally one child remains for days or even weeks after the birth of the first one before it is delivered and thus completes its development. A pregnant woman submitting to coitus during the early months of gestation may have a second ovule impregnated (superfetation). The fetuses may be born at different times. (For cases see Taylor's Jurisprudence, p. 487; Leishman's Midwifery, pp. 186-8; Playbair's Midwifery, pp. 161-2; Churchill's Midwifery, pp. 177-8.) The occurrence of superfetation has been questioned, but its possibility and its actual occurrence as a matter of fact are now generally admitted."

In Vol. VI, p. 5, of the "Reference Handbook of the Medical Sciences" we find that "There are a few instances recorded where the fecundation was successive, so that it may be admitted that a woman who has already conceived may, while the product of conception remains, conceive again-in other words superimpregnation may occur."

Back of this the theory of menstruation, ovulation and impregnation may give a considerable light. Does menstruation always cease at the beginning of pregnancy? Experience teaches us that there are exceptions, and perhaps every practitioner present has had cases that continued to menstruate more or less regularly for one, two or more months.

The ovulatory theory holds that menstruation is nature's

preparation of the uterus for the reception and growth of the impregnated ovum. King says: "About the time when the ovule is ripe and soon to be discharged, the reproductive organs, especially the ovaries and uterus, receive an extra amount of blood-they become physiologically congested in anticipation of impregnation." The function of the ovary is the production of the seed, so to speak; that of the uterus is preparation of the soil suitable to its development. A spermatozoon after coitus ascends through the uterus and Fallopian tube meeting an ovule most probably in its directing channel of fimbriated extremity, fertilizing it, and the resulting ovum finds suitable lodgment on the uterine wall. The deciduous membrane has been formed, but the monthly proclivity of nature to prepare the soil is now changed and permanent, regular provision for nutrition is now to be provided. Now instead of the monthly formation of a hypertrophied deciduous membrance anticipating the lodgment and growth of the ovum, only to undergo fatty degeneration and be thrown off in case an ovum is not lodged for growth-we have the decidua formed permanently, growing and lining the entire uterine cavity. For two reasons the menstruation generally ceases upon impregnation, viz.: First, because there is no further necessity; second, because this supply of blood is turned to the nutrition of the developing fetus. But there are cases in our practice in which menstruation continues for the first few months. Playbair, pp. 136-7, says: "During the first months of gestation, when the ovum is not yet sufficiently advanced in growth to fill the whole uterine cavity, there is a considerable space between the decidua reflexa which surrounds it, and the decidua vera lining the uterine cavity; it is from the free surface of the decidua that the periodical discharge comes, and there is not only ample surface for it to come from, but a free channel for its escape through the os uteri."

Ovulation and menstruation are coincident and coexistent; the former is the real primary female function, the latter the attendant and apparent function. These precede conception, but the ovary is the prime necessity and instigator, so to speak; the uterus the aid and attendant. There is no necessity asserted by nature for menstruation unless there is a prompting ovulation, so we believe the Graafin follicles rupture and throw off ovules whenever instigated menstruation appears. These two occurring at any time paves the way for the fertilization of a spermatozoon of adapted temperament. Does the uterus-can it-during gestation present a suitable soil for the devel ment of the ovum? A hypertrophy of the uterus, especially the mucous membrane, and increased blood-supply presents the soil as evinced by menstruation. If this funetion can be and is performed during gestation, as is undisputed, does or does not a coitus with its sequent fertilization of the ovule into an ovum, and the uterine ground ready, suggest that superimpregnation might occur. If the uterus performs its monthly function as the ovary requires in some cases and an ovum finds lodgment in this soil prepared for it, can it not grow in this soil and a second fetus result in the same uterus?

"There are," says Playbair, "a sufficient number of authenticated cases of menstruation during pregnancy to prove that ovulation is not always absolutely in abeyance; and, as long as it occurs, there is unquestionably no positive mechanical obstruction, at least in the early months of pregnancy in the way of impregnation and lodgment of the ovules that are thrown off. The reasonable conclusion, therefore, seems to be that, although a large majority of the cases are explicable in other ways, it can not be admitted that superfetation is either physiogically or mechanically impossible."