CONJOINED TWINS: SITUS INVERSUS VISCERA. RITTA AND CHRISTINA PARODI. FROM ÉTIENNE SERRES 1832 Recherches d’anatomie transcendante et pathologique.
This condition, known as situs inversus, literally ‘position inverted’, is common in conjoined twins, as it is rare in the rest of us (who are situs solitus). Not all conjoined twins are situs inversus, but only those that are fused side to side (rather than head to head or hip to hip). Even among side-to-side twins situs inversus is only ever found in the right-side twin – ‘right’ referring to the twins themselves not the observer’s view of them – and then only in 50 per cent of them. This last statistic is intriguing, for it implies that the orientation of the viscera is randomised in right-side twins. It is as if nature, when arranging their internal organs, abandons the determinism that rules the rest of us, and instead flips a coin marked ‘left’ or ‘right’.
In recent years, much has been learned about why our internal organs are oriented the way they are. One source of information comes from those rare people – the best estimates put them at a frequency of 1 in 8500 – who, despite being born without a twin, have internal organs arranged the wrong way round. The most famous historical case of singleton situs inversus was an old soldier who died at Les Invalides in 1688. Obscure in life – just one of the thousands who, at the command of Louis XIV, had marched across Flanders, besieged Valenciennes and crossed the Rhine to chasten German princelings – he achieved fame in death when surgeons opened his chest and found his heart on the right. In the 1600s Parisians wrote doggerel about him; in the 1700s he featured in the querelle des monstres debate; in the 1800s he became an example of ‘developmental arrest’, the fashionable theory of the day. Were he to appear on an autopsy slab today, he would hardly be famous, but would simply be diagnosed as having a congenital disorder called ‘Kartagener’s syndrome’.
It is a diagnosis that allows us to reconstruct something of the old soldier’s medical history. Although the immediate cause of his death is not known, it certainly had nothing to do with his inverted viscera. He was, indeed, in all likelihood oblivious to his own internal peculiarities. Although he was quite healthy (dying only at the age of seventy-two), he probably never fathered any children, and his sense of smell was also probably quite poor. We can guess these things because inverted viscera, sterility and a weak sense of smell are all features of men with Kartagener’s.
That the association between these symptoms was ever noticed is surprising, for they seem so disparate, and even after the syndrome was first defined in 1936 the causal link between them remained elusive for years. But in 1976 a Swedish physician named Bjorn Afzelius found that a poor sense of smell and sterility are caused by defective cilia – the minute devices that project from the surfaces of cells and wave about like tiny oars. Cilia clear particles from our bronchial passages, and the tail that drives a spermatozoon to its destination is also just a large sort of cilium. Each cilium is driven by a molecular motor, a motor that in people with Kartagener’s syndrome does not work. As children, for want of beating cilia to clear the passages of their lungs and sinuses they have chronic bronchitis and sinusitis – hence the poor sense of smell. As adults, the men are sterile for want of mobile sperm. At the heart of the ciliary motor lies a large protein complex called dyenin. It is made up of a dozen-odd smaller proteins, each of which is encoded by its own gene. So far Kartagener’s syndrome has been traced to mutations in at least two of these genes, and it is certain that others will be found.
KARTAGENER’S SYNDROME. DISSECTED INFANT SHOWING SITUS INVERSUS VISCERA. FROM GEORGE LECLERC BUFFON 1777 Histoire naturelle générale et particulière.
But it is the situs inversus that is so intriguing. Afzelius noted that not all people with Kartagener’s syndrome have inverted viscera: like conjoined twins, only half of them do. He suggested, insightfully, that this implied that cilia were a vital part of the devices that the embryo uses to tell left from right – but what their role was he could not say. Only in the last few years has the final link been made – and even now there is much that is obscure. It all has to do with (and this is no surprise) the organiser.
I said earlier that the organiser is a group of mesodermal cells located at one end of the embryo’s primitive streak. Each of these cells has a single cilium that beats continually from right to left. Collectively they produce a feeble, but apparently all-important, current in the fluid surrounding the embryo, an amniotic Gulf Stream. This directional movement, and the cilia whose ceaseless activity causes it, is the first sign that left and right in the embryo are not the same. The mechanism, which was only discovered in 1998, is wonderfully simple and, as far as is known, is used nowhere else in the building of the embryo. What the cilia actually do is unclear; the best guess is that they concentrate some signalling molecule on the left side of the embryo, rather as foam accumulates in the eddies of a river.
This model (with its Aristotelian overtones) is frankly speculative, but it makes sense in the light of what happens next. Shortly after the organiser forms, genes can be seen switching on and left and right in the cells that surround it. They encode signalling molecules that transmit and amplify the minute asymmetries established by the organiser’s beating cilia to the rest of the embryo. One might call it a relay of signals, but that suggests something too consensual. It is more like a hotly contested election. In democracies left and right battle for the heart of the polis; so it is in embryos as well.
There is a lovely experiment that proves this. If the various signals that appear early in the embryo’s life on either side of the organiser are indeed involved in helping it tell left from right, then it should be possible to confuse the embryo by switching the signals around. As usual, this is a hard trick to do in mammal embryos, but not that difficult in chickens. By gently cutting open a recently-laid egg and so exposing the embryo as it lies on its bed of yolk, it is possible to gently place a silicone bead soaked in ‘left-hand’ signal on its right (or to place a bead soaked in ‘right-hand’ signal on its left). Either way, the asymmetry of the embryo’s signals is destroyed. And so too, it becomes apparent shortly thereafter, is the asymmetry of the chicken’s heart. Where once it always fell to the left, it now has an even probability of falling to either side. The resemblance of this randomisation to that found in people with Kartagener’s syndrome and in conjoined twins is surely no coincidence. Indeed, it is thought that Ritta’s inverted heart was caused by just such a scrambled molecular signal. When the girls were nothing more than primitive streaks lying side by side, each strove to order her own geometry. But in Ritta’s case this effort was confounded by signals that swept over from her left-hand twin. The molecular asymmetries upon which her future geometry depended were abolished, and from that point on the odds were fifty–fifty that her heart would be placed the wrong way round.
In 1974 Clara and Altagracia Rodriguez became the first conjoined twins to undergo successful surgical separation. Since then, the birth of each new pair – Mpho and Mphonyana (b.1988, South Africa), Katie and Eilish (b.1989, Ireland), Angela and Amy (b.1993, USA), Joseph and Luka (b.1997, South Africa), Maria Teresa and Maria de Jésus (b.2002, Guatemala), to name but a few – has been the occasion of a miniature drama in which surgeons, judges and parents have been called upon to play the part of Solomon. Surgical advances nothwithstanding, had Ritta and Christina Parodi been born today they could not have been separated. But they would surely have lived. Somewhere in America, Brittany and Abigail Hensel, twins even more closely conjoined than they, have recently turned twelve.
Jules Janin never wrote his novel of Ritta and Christina Parodi’s unlived lives. But he did leave an outline of what he had in mind. No translation could do justice to the turbulence of his prose, but a paraphrase gives an idea. In Janin’s world, far from being born to poverty (after all, ‘la misère gâte tout ce qu’elle touche’), the two girls are rather well off. They also, inexplicably, have different-coloured hair. Christina, who is blonde, strong and no
ble, watches tenderly over her weaker, slightly sinister sibling, who is, inevitably, the brunette. All is harmonious, but suddenly seventeen springs have passed and, arrive l’Amour, in the shape of a bashful Werther who loves, and is loved by, only one of them – Christina, of course. Ah, the paradox! Two women, one heart, one lover; it is too tragic for words. Ritta sickens, and a mighty struggle between life and death ensues, as when un guerrier est frappé à mort. The sisters expire and we leave them having, as Janin puts it, ‘arrived at new terrors, unknown emotions’, and a sense of relief that he never wrote the full version.
The reality was, of course, quite different. When Serres had done with Ritta and Christina he not only kept the skeleton but quite a few other body-parts as well. An old catalogue of the Muséum d’Histoire Naturelle lists, in a copperplate hand, separate entries for the infants’ brains (Cat. No. 1303 and 1304), eyes (1306, 1307), tongues (1308, 1309) and various other bits and pieces. Most of these specimens now seem to be lost, though it is possible that they will one day surface from the museum’s underground vaults. Ritta and Christina’s skeleton, however, is still around – as is the painted plaster-cast of their body. Both are on display in the Gallery of Comparative Anatomy, a steel-vaulted structure with an interior like a beaux-arts cathedral that stands only a few hundred metres from the amphitheatre where the sisters were first dissected.
A Gallery of Comparative Anatomy may seem like an odd place to exhibit the remains of two small girls. Nearly all of the hundreds of other skeletons there belong to animals, arranged by order, family, genus and species. Yet, from one point of view, there could hardly be a better place for them. The gallery represents the cumulative effort of France’s greatest naturalists to impose order upon the natural world; to put each species where it should be; to make sense of them. For Étienne Geoffroy Saint-Hilaire the study of congenital deformity was, in the first instance, much in this spirit – a matter of locating conjoined twins in the order of things. In a gesture that Geoffroy would have loved, Ritta and Christina’s remains share an exhibition case with a pair of piglets and pair of chicks that are conjoined much as they were. Such specimens were, to him, pickled proof that deformity is not arbitrary, a caprice of nature, a cosmic joke, but rather the consequence of natural forces that could be understood. ‘There are no monsters,’ he asserted, ‘and nature is one.’ In the way of French aphorisms, this is a little cryptic. But if you stand in front of the display case containing what is left of Ritta and Christina Parodi and look at the pink plaster-cast of the body with its two blonde heads and four blue eyes, it’s easy to see what he meant.
III
THE LAST JUDGEMENT
[ON FIRST PARTS]
IN 189O THE CITIZENS OF AMSTERDAM bought Willem Vrolik’s anatomical collection for the sum of twelve thousand guilders. It contained 5103 specimens, among them such rarities as the skull of a Sumatran prince named Depati-toetoep-hoera who had rebelled, apparently with little success, against his colonial masters. There was also a two-tusked Narwhal skull that had once belonged to the Danish royal family, an ethnographic collection of human crania, and the remains of 360 people displaying various congenital afflictions. Some of the specimens were adult skeletons, but most were infants preserved in alcohol or formaldehyde.
The Vrolik is just one of the great teratological collections that were built up during the eighteenth and nineteenth centuries. London’s Guy’s and St Thomas’s Hospital has the Gordon collection, while the Royal College of Physicians and Surgeons has the Hunterian; Philadelphia has the Mütter; Paris the Muséum d’Histoire Naturelle as well as the Orfila and the Dupuytren. Vrolik’s collection, which was given to the medical faculty of the University of Amsterdam, now occupies a sleek gallery in a modern biomedical complex on the outskirts of the city. What makes it unusual, if not unique, is that where most teratological collections are closed to all but doctors and scientists, the curators of the Vrolik have opened their collection to the public. In a fine display of Dutch rationalism they have decided that all who wish to do so should be allowed to see the worst for themselves.
CYCLOPIA. STILLBORN INFANT, FIRME, ITALY (1624). FROM Fortunio Liceti 1634 De monstrorum natura caussis et differentiis.
And the worst is terrible indeed. Arrayed in cabinets, Vrolik’s specimens are really quite horrifying. The gaping mouths, sightless eyes, opened skulls, split abdomens and fused or missing limbs seem to be the consequence of an uncontainable fury, as if some unseen Herod has perpetrated a latter-day slaughter of the innocents. Many of the infants that Vrolik collected were stillborn. A neonate’s skeleton with a melon-like forehead is a case of thanatophoric dysplasia; another whose stunted limbs press against the walls of the jar in which he is kept has Blomstrand’s chondrodysplasia. There is a cabinet containing children with acute failures in neural tube fusion. Their backs are cleaved open and their brains spill from their skulls. Across the gallery is a series of conjoined twins, one of which has a parasitic twin almost as large as himself protruding from the roof of his mouth. And next to them is a specimen labelled ‘Acardia amorphus’, a skin-covered sphere with nothing to hint at the child it almost became except for a small umbilical cord, a bit of intestine, and the rudiments of a vertebral column. Until one has walked around a collection such as the Vrolik’s it is difficult to appreciate the limits of human form. The only visual referent that suggests itself are the demonic creatures that caper across the canvases of Hieronymus Bosch – another Dutchman – that now hang in the Prado. Of course, there is a difference in meaning. Where Bosch’s grotesques serve to warn errant humanity of the fate that awaits it in the afterlife, Vrolik’s are presented with clinical detachment, cleansed of moral value. And that, perhaps, suggests the best description of the Museum Vrolik. It is a Last Judgement for the scientific age.
THE CYCLOPS
Of Willem Vrolik’s published writings, the greatest is a full folio work that he published between 1844 and 1849 called Tabulae ad illustrandam embryogenesin hominis et mammalium tarn naturalem quam abnormem (Plates demonstrating normal and abnormal development in man and mammals). The teratological lithographs that it contains are of a beauty and veracity that have never been surpassed. The richest plates are those devoted to foetuses, human and animal, that have, instead of two eyes, only one – a single eye located in the middle of their foreheads. By the time Vrolik came to write the Tabulae he had been studying this condition for over ten years, had already published a major monograph on it, and had assembled a collection of twenty-four specimens – eight piglets, ten lambs, five humans and a kitten –that displayed this disorder in varying degrees of severity. Following Geoffroy he gave the condition a name that recalled one of the more terrible creatures in the Greek cosmology: the Cyclops.
Hesiod says that there were three Cyclopes – Brontes, Steropes and Arges – and that they were the offspring of Uranus and Gaia. They were gigantic, monstrous craftsmen who in some accounts made Zeus’ thunderbolts, in others, the walls of Mycenae. The Cyclopes of the Odyssey are more human and more numerous than those of the Theogony, but their single eye is still a mark of savagery. Homer calls them ‘lawless’. Polyphemus is more lawless than most: he has a taste for human flesh and dashes out the brains of Ulysses’ companions ‘as though they had been puppies’ before eating them raw. Homer does not identify the island where the renegade Cyclops lived, but Ovid put him on the slopes of Etna in Sicily and gave him an affecting, if homicidal, passion for the nymph Galatea. Painted on vases, cast in bronze or carved in marble, Polyphemus was depicted by the Greeks throwing boulders or else reeling in agony as Ulysses drives a burning stick into his single eye.
Many teratologists have linked the deformity to the myth. They argue that the iconographic model for the semi-divine monster was a human infant. Certainly the model, if it ever existed, must have been only faintly remembered. Differences in size and vigour aside, even the earliest representations of Polyphemus put his single eye where you would expect it, above his nose. Bu
t the single eye of a cyclopic infant invariably lies beneath its nose – or what is left of it. Others have argued, more or less plausibly, that the Cyclopes were inspired by the semi-fossilised remains of dwarf elephants that litter the Mediterranean islands.
Whatever its origins, Homer to Vrolik, the iconography of the Cyclops shows a clear evolutionary lineage. Homer’s Polyphemus is monstrous; Ovid’s is too, although he is also a sentimentalist. But within sixty years of the poet’s death in 17 ad, the Cyclops would appear in a different guise. It would become a race of beings that had ontological status, supported by the authority of travellers and philosophers. In 77 ad Pliny the Elder finished his encyclopaedic Historia naturalis. Drawing on earlier Greek writers like Megasthenes, who around 303 bc travelled as an ambassador to India in the wake of Alexander the Great’s conquests, Pliny peopled India and Ethiopia (the two were barely distinguished) with a host of fabulous races. There were the Sciapodes, who had a single enormous foot which they used as a sort of umbrella; dwarfish Pygmies; dog-headed Cynocephali; headless people with eyes between their shoulderblades; people with eight fingers and toes on each hand; people who lived for a thousand years; people with enormous ears; and people with tails. And then there were the single-eyed people: Pliny calls them the Arimaspeans and says that they fight with griffins over gold.
This was the beginning of a tradition of fabulous races that persisted for about fifteen centuries. By the third century ad, Christian writers had adopted the tradition; by the fifth century, St Augustine is wondering whether these races are descended from Adam. In the Middle Ages, the Cyclopes appears essentially unaltered from antiquity in manuscripts of wonder-books such as Thomas a Cantimpré’s De Naturis Rerum which was composed around 1240. In the fourteenth century, their biblical parentage is settled: they are the deformed descendants of Cain and Ham. Around the same time they appear in illuminations of Marco Polo’s travels (the Italian unaccountably fails to mention their existence); in the early 1500s one appears on the wall of a Danish church dressed in the striped pantaloons, floppy hat and leather purse of a late-medieval Baltic dandy. With time, the Cyclops becomes smaller, tamer and moves closer to home.
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