REPORT OF AN AUTOPSY ON THE BODIES OF CHANG AND ENG BUNKER, COMMONLY KNOWN AS THE SIAMESE TWINS

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   REPORT

   OF

   AN AUTOPSY ON THE BODIES

   OF

   CHANG AND ENG BUNKER,

   COMMONLY KNOWN AS THE

   SIAMESE TWINS

   BY

   HARRISON ALLEN, M.D.,    PROFESSOR OF
COMPARATIVE ANATOMY AND ZOÖLOGY IN THE
UNIVERSITY OF         PENNSYLVANIA,
SURGEON TO THE PHILADELPHIA HOSPITAL,
ETC.

   PHILADELPHIA:
COLLINS, PRINTER, 705 JAYNE STREET.
1875.

   AUTOPSY OF THE SIAMESE TWINS.

   [Illustration Figure 1:

   Fig. 1.   The twins in the acquired
position (E. R., C. L.). From a
photograph taken in St. Petersburg,
1870. ]

   NOTE.

   The word “Report” used in the title
of my paper is to be read as referring
to the post-mortem appearances only, and
not to the Report of the Commission as
appointed by the College. The ante-
mortem history prefixed to my paper was
written in conjunction with Prof.
Pancoast.

   H. ALLEN.

   REPORT

   OF AN

   AUTOPSY ON THE BODIES OF CHANG AND
ENG                      BUNKER,
COMMONLY KNOWN AS THE
SIAMESE TWINS.

   By

   HARRISON ALLEN, M.D.,      PROFESSOR
OF COMPARATIVE ANATOMY AND ZOÖLOGY IN
THE UNIVERSITY       OF PENNSYLVANIA,
SURGEON TO THE PHILADELPHIA HOSPITAL,
ETC.

   [Read April 1, 1874.]

   -------

   ANTE-MORTEM HISTORY.

   Chang and Eng Bunker were born near
Bangkok, Siam, in 1811, their father
being a Chinaman, their mother a native
of Siam, bred by a Chinese father.[1]

   -----

   Footnote 1:

   For this statement see an article in
Lippincott’s Magazine, March,   1874.

   -----

   The twins were united by a band
extending from the junction of the
abdominal and thoracic cavities,
anteriorly, constituting the variety in
teratology known as _Omphalopagus
xiphodidymus_.

   They were married in April, 1843, and
raised large families; Chang having had
ten, and Eng twelve children. Chang had
three boys and seven girls; Eng had
seven boys and five girls. These were in
all respects average children, excepting
two, a boy and girl of Chang’s, who were
deaf-mutes.

   The twins resided in a rolling
country, about four miles from Mount
Airy, Surrey Co., N. C. They were
prosperous farmers, each owning his own
farm. The dwellings of the two families
were a mile and a half apart. The twins
resided three days in each of the homes
alternately. They were expert in the
handling of tools, in plowing,
shingling, shooting, etc. They lived
much in the open air, and frequently
drove in a carriage to the neighboring
village.

   The events leading to their death
were as follows: About six years ago
Chang, who had always been the more
excitable, became addicted to immoderate
drinking. Three years ago, while on a
voyage from Liverpool to New York, he
was stricken with hemiplegia of the
right side. He in great measure
recovered from this attack, but could
never ascend and descend stairs with
facility. For this reason the twins
occupied rooms on the ground floors of
their homes.

   On Monday evening, Jan. 12th, 1874,
Chang was seized, while at his own
house, with an attack of bronchitis. He
had a cough; scanty, frothy sputa; but
no pain. On Wednesday the symptoms had
somewhat subsided; the skin was acting
freely. Loud bronchial râles were
present over the left side of the chest.
On Thursday evening the twins insisted
upon leaving Chang’s house for Eng’s.
The weather was very cold, and the
journey was undertaken in an open
carriage. On their arrival, however,
Chang continued as well as before, until
Friday evening, when he complained of
thoracic oppression and inability to lie
down with comfort. After having retired
that evening, the twins were heard to
get up, and go out on the porch, by the
side of the house, where they drank of
water, and returned to their room. They
built a large wood fire, and sat down;
Eng soon complaining of being sleepy,
Chang declaring that he could not
breathe if he should lie down. Finally
they again retired. They both fell
asleep. Near daybreak (Jan. 17th) Eng
called to one of his sons, who slept in
a room above, to come down and waken
Chang. The boy soon made his appearance,
and going to the side of Chang, cried
out, “Uncle Chang is dead!” Eng at once
said “Then I am going!”—It is probable
that Chang was sleeping when he died.

   Eng made no further mention of Chang
other than to request that the body be
moved closer to him. Soon afterward Eng
desired to have his limbs moved. This
desire continued for half an hour. He
then asked for a urinal, but did not
void over a few drops of urine. He
several times repeated the endeavor to
micturate, but without success. He then
complained of a choking sensation, and
asked to be raised in bed. He had
continued rational. His last words were
“May God have mercy on my soul!” He
gradually became fainter, fell into a
syncopal state, and died quietly a
little over two hours from the
announcement to him of the death of his
brother.

   AUTOPSY.

   The Autopsy was begun in the house of
Eng, Sunday, February 1st, 1874, and
finished in the Mütter Museum of the
College of Physicians, at Philadelphia.

   Age of subjects, 63 years.
Examination made about fifteen days and
eight hours after death. The weather had
been cold. No preservative had been
employed prior to the date of the
autopsy.

   I. Post-mortem Appearances.

   The following is their description in
Chang.

   Body moderately emaciated. _Rigor
mortis_ none. The fingers of the right
hand were semi-flexed, a condition due
doubtless to the long-standing paralysis
of the right upper extremity. Passive
congestion was marked over entire dorsal
aspect of the neck, trunk, and upper
extremities. It was less marked over the
corresponding surfaces of the forearm
and legs. The feet and hands were almost
entirely free. The superficial veins in
the last-named localities, especially in
the left foot, were distended. The
passive congestion extended over the
right thoracic region as far as the
median line, and on the front of both
thighs, especially the right. Upon the
head the congestion was seen behind and
beneath the ears, and was sparsely
distributed over both malar prominences.
The lips were discolored. The integument
of the genitals was infiltrated, the
scrotum particularly being much swollen.
There was extensive greenish
discoloration on the anterior abdominal
wall. The left external abdominal ring
was enlarged. Both testicles were within
the scrotum. The hair of the head was
gray. That on the right side of the
pubis was black, that on the left was of
an iron-gray color.

   The following is their description in
Eng.

   Body moderately well nourished,
spare. _Rigor mortis_ slight. Passive
congestion less marked than in Chang. It
was most conspicuous on the buttocks and
infraspinous spaces. There was none in
front of the body. The testicle of left
side absent from scrotum. There was
moderate greenish discoloration of
anterior wall of abdomen. The hair on
the pubis was black on the right side,
pure gray on left side of the median
line.

   _Measurements._—Chang was 5 ft. 2-1/2
in. in height; Eng, 5 ft. 3-1/2 in. When
the bodies were laid upon a table
Chang’s left side and Eng’s right side
were drawn somewhat toward one another.
This was most marked in Chang, and gave
a greater inclination of his trunk
toward his brother’s. (See Figs. 1 and
19.)

   II. External Appearances of the Band.

   When the bodies were suspended and
placed face to face, it was evident that
the congenital position had been
secured. All observations were made, as
far as was possible, with the bodies in
this position. With it the details of
structure, it was thought, could be
easily understood; without it the
subject would be difficult and confused.

   The “band” was a massive commissure
placed between the bodies at the
junction of the abdominal and thoracic
regions of each. It was broader above
than below, and had a circumference of
nine inches. It presented four surfaces
for examination, an upper, lower, and
two lateral surfaces.

   The _upper_ surface was somewhat
flattened in both Chang and Eng. The
ensiform cartilage of each body could be
felt deflected from the sternum and
prolonged into the band. The base of the
cartilage in Eng presented a rounded
circular eminence, measuring one inch in
diameter. There was no corresponding
eminence in Chang. The upper aspect of
each process could be well defined
beneath the skin, the subcutaneous
connective tissue being more abundant in
Chang than in Eng. The upper surface
measured 2-1/2 in. in width at its base
towards Eng, and 2-1/3 in. at its base
towards Chang. It was 2 in. wide at its
middle.

   [Illustration Figure 2:

   Fig. 2.   The twins in the acquired
position (E. R., C. L.), showing
band and the primary incisions, _a-b_,
_c-d_. From a             photograph
taken after death at Philadelphia. ]

   The _lower_ surface was much narrower
than the upper. It was marked in the
centre, but nearer the anterior than the
posterior border, by a linear scar one
inch in length, which it was thought
answered to the position of the single
umbilicus. The skin was adherent at this
point, but elsewhere was easily raised
in folds. Behind the scar, _i. e._,
toward the posterior part of the band,
the skin was somewhat corrugated. This
portion answered, in position, to
Chang’s umbilical pouch.

   The _lateral_ surfaces. The terms
_upper_ surface and _lower_ surface have
fixed values, no matter how they may be
approached by the observer. This is not
the case, however, with the lateral
surfaces, as will appear from the
following considerations. Viewing the
band as a separate form—as it was spoken
of during the life of the twins—we will
see that the terms front (“anterior”)
and back (“posterior”), as given to the
lateral surfaces, were derived from
studying the acquired position. Thus we
were bound not to cut the “front” of the
band, but allowed to make an incision on
the “back.” Now this position of
selection was destroyed, and its terms
deprived of what meaning they may have
had, by the reproduction of the
congenital relations of the bodies.

   There is no doubt that in infancy and
early childhood there was no acquired
position, and, therefore, neither
“front” nor “back” to the band. And
later, when, as we have reason to
believe, the position of selection was
gradually adopted, the terms “front” and
“back” were reversible—the “front”
meaning that which corresponded to the
surface of least thoracic approximation.
Thus when the adult condition was fixed,
and the “front” answered to the widely
separated right side of Eng’s chest and
left side of Chang’s chest, the “back”
was in relation with the closely
approximated left side of Eng’s chest
and right side of Chang’s.

   To avoid awkward repetition of
phrases expressing the facts of the last
sentence, the following characters will
be employed in describing the “lateral”
surfaces of the band.

   E. R., C. L. (Eng’s right, Chang’s
left) will designate the “anterior”
surface of the acquired position. C. R.,
E. L. (Chang’s right, Eng’s left) will
designate the “posterior” surface. Since
the right side of Chang’s half of the
band merged into the left on Eng’s half,
while the right side of Eng’s half,
after it passed the middle line, became
the left half of Chang’s, we propose
using the characters E. L., E. R., and
C. R., C. L., which will be understood
as signifying left side Eng, right side
Eng, etc.

   Using the above signs we found that
the surface E. R., C. L. was inclined
decidedly downward and backward when
seen in the congenital position, and was
3 in. high and 2-1/2 in. wide. At E. R.,
the border answering to the ensiform
cartilage was marked by a large rounded
tubercle; it was much more pronounced
than on the corresponding border of C.
L. When seen in the acquired position,
E. R., C. L. became “anterior,” when, at
its upper margin, C. L. was longer than
E. R. by one-half inch. The tubercle on
E. R., already noticed, was much more
prominent than C. L. The contour of the
inferior margin was also different,
being more uneven. C. L. was not only
longer, but was more obliquely placed
downward and outward to the centre of
the band than E. R. (See cast in the
Mütter Museum.)

   III. Coverings of the Band.

   In front (E. R., C. L.) the
superficies could not be well examined
owing to the restrictions imposed by the
families. A view of it from within can
be obtained in Figs. 8, 9, _q. v._
Permission having been granted to make
an incision “behind,” at C. R., E. L., a
modified letter-H incision was employed,
thus—

   a  \       / e
b  >—————< d
c  /       \ f

   Turning the skin flaps here indicated
upwards and downwards, and the lateral
triangles outwards, there was found
beneath, a layer of superficial fatty
connective tissue, with a well-defined
layer of fat on either side, but with an
intermediate portion which was free from
fat, and of greater thickness.

   The skin could with some little
trouble be raised over the _dorsal or
upper surface_, showing here entire
absence of fat. A very delicate artery
was found running across the middle,
from Eng to Chang.

   The lower portion of the surface C.
R., E. L. was inseparably connected with
the umbilicus. It was also united to the
superficial fascia on C. L., about 1-1/2
inches from the umbilicus; this did not
have any connection with the deeper
parts. The process of fibrous tissue
which had been felt through the skin was
conspicuous on this surface of the band,
and was covered by a delicate non-fatty
layer of connective tissue. Towards the
lower part of the surface were seen
several diverging lines of fibrous
tissue, which were lost within the
integument about the umbilical scar, at
the lower surface of the band. They were
exceedingly thin, and at one point lay
directly over the posterior and inferior
wall of the umbilical pouch of Chang.

   [Illustration Figure 3:

   Fig. 3.   The surface, C. R., E. L.,
exposed by removal of skin and
superficial fascia to display the
tendons of the external
oblique muscles and adjacent parts.

   A.   The superficial fascia—lost over
the position of Chang’s
umbilical pouch.

   B, C.   Supplemental layers of
fibrous tissue of Eng not seen in
Chang; B is a continuation toward Eng of
aponeurotic             fibres having a
source from the linea alba of Chang; C
is             independent of the
former, and is continuous with the deep
pectoral fascia.

   D.   The interlacing of fibres on
tendon of external oblique
muscle of Chang.

   E.   The linea alba of Chang,
beginning at C. R.

   F.   Its continuation to E. L., and
insertion upon the ensiform
cartilage. ]

   Turning down the superficial layer,
the aponeurosis of the external oblique
muscle was exposed (Fig. 3). A marked
contrast was exhibited in the two sides
of the band. In Chang the parts were
normal so far as they were exposed—the
characteristic apertures for the escape
of small vessels being abundant and
conspicuous. In turning down the
superficial fascia in Eng (Fig. 3, A),
it was found to be continuous at its
lower portion with an aponeurotic layer
(Fig. 3, B), which extended toward the
median line, where it was continuous
with the linea alba of Chang. In
addition to this, a second layer (Fig.
3, C), analogous in position to a deep
layer of the superficial fascia, which
was entirely independent of Chang,
extended over nearly the whole of Eng’s
division, and was particularly well
defined over the fibres of origin of the
external oblique muscle. This was
continuous with the deep layer of the
superficial fascia which passed over the
entire side of Eng’s thorax.

   Toward the middle of the band this
layer gradually lost its distinctive
features, and was firmly incorporated
with the tendon of the external oblique
muscle. A number of fibres corresponding
to it extended in inseparable intimacy
with this tendon. These were gradually
lost as they approached the linea alba
of Chang, and the parts being in
position these fibres were at their
lower portion covered in by the
aponeurotic extension of the linea alba
already mentioned.

   On Chang’s side, as we have seen, the
parts comparable to these accessory
layers were absent. There was no line of
demarcation between the tendon of the
oblique and the aponeurotic attachment
of the pectoralis. The tendon of the
external oblique presented a different
appearance from the normal one in a more
extensive interlacing of fibres of the
linea alba with the tendon.

   The part termed above the linea alba
of Chang (Fig. 3, E), has already been
indicated through skin and superficial
fascia. As can be seen, this band of
fibres, having its origin from the
middle line of the abdomen of Chang, was
found to be a direct continuation of the
linea alba. It was remarkable in not
being inserted into the ensiform process
of Chang, but into that of Eng, and in
giving off the aponeurotic outshoot B,
already noticed, as well as in having a
diffused point of insertion into Eng’s
tissue as in the ensiform cartilage (F).
In a word, the linea alba approaches the
surface C. R., E. L. from C. R. below,
and is inserted into E. L. above.

   IV. Organs Of Abdomen as observed in
position through the Incisions.

   Limited incisions being alone
permitted, the large vessels of the
abdomen were sought for in the process
of embalmment, believing, as we did,
that the procedures of securing them
would enable us, by extending the cuts
from below upward, to fairly open the
abdomen and examine thereby the interior
of the band.

   In each body, therefore, an incision
six inches long (Fig. 2, _ab_, _cd_) was
extended from the centre of the right
iliac region to the centre of the right
hypochondriac region. This was
subsequently joined by an oblique
incision passing from the upper end of
the first mentioned to the lateral
border of the ensiform cartilage at its
base. This incision measured 7-1/2 in.
The lower end of the vertical incision
was met by a horizontal one passing to
the centre of the hypogastric region,
and measuring 3-1/4 in.

   Through these incisions were studied
(1) the _umbilical ligaments_ and (2)
_the abdominal viscera_.

   1. _The umbilical ligaments._[2]—By
turning forward the anterior flap in Eng
as far as possible, the peritoneal
lining was exhibited, and there was
brought into view a structure beginning
at the summit of the bladder, and which,
ascending the abdominal wall and passing
obliquely to the right side, could be
traced clearly to the scar-like tissue
marking the remains of the umbilical
structures situated upon the anterior
abdominal wall within about 1-1/2 in. of
the band. This structure was the
umbilical ligament (Fig. 4, A). It was
loaded with fat, and, as it terminated
at the scar, distinct lobules of fat
(several of which were pedunculated)
were abundantly deposited.

   The bladder was distended and raised
5 in. above the pubis.

   -----

   Footnote 2:

   The folds of peritoneum containing
remains of the hypogastric arteries
will be called throughout by the name of
_the umbilical ligaments_.

   -----

   [Illustration Figure 4:

   Fig. 4.   The umbilical ligament in
Eng.

   A.   The umbilical ligament.

   B.   The lobule of fat at position of
the normal umbilicus. ]

   In Chang (Fig. 5), the same
appearances were seen as those above
given, save that no fat was deposited in
the umbilical ligament. On the contrary,
it resembled the omentum of an emaciated
subject. When stretched, the fold was
fully an inch wide, quite transparent,
and marked by two longitudinal bands,
which recalled the shapes of the
obliterated vessels. But two rather
small sessile fatty appendages were seen
at the scar.

   The bladder was empty, contracted,
and lay within the true pelvis.

   [Illustration Figure 5:

   Fig. 5.   The umbilical ligament in
Chang.

   A.   The umbilical ligament.

   B.   The lobule of fat at position of
the normal umbilicus. ]

   In both Chang and Eng an isolated
mass of subperitoneal fat, presenting a
sub-circular form, and measuring 1 in.
in diameter, was found in the position
of the normal umbilicus (Figs. 4 and 5).

   2. _The viscera._—In Eng the omentum
was gathered up toward the transverse
colon. It was abundantly furnished with
fat.[3] The transverse colon extended
across the abdomen, beginning on the
right side on a level with the eleventh
rib. It was contracted and contained a
little flatus. The rest of the exposed
region was occupied by coils of small
intestine, yielding a mesentery very
rich in fat. The stomach was not
visible. By removing the small
intestine, and bringing down the
transverse colon and large intestine,
the pyloric extremity of the stomach was
seen. The fundus of stomach, spleen, and
left kidney were not seen. (Fig. 6.)

   -----

   Footnote 3:

   The presence of a great amount of
adipose tissue throughout, in Eng,   was
very noticeable as contrasted with the
emaciated appearance of the   tissues in
Chang.

   -----

   [Illustration Figure 6:

   Fig. 6.   The abdominal organs in
Eng—the small intestines removed.

   A.   Left lobe of liver.

   B.   Right lobe of liver.

   C.   Gall-bladder.

   D.   Suspensory ligament.

   E.   Lobules of fat in the position
of the termination of the
umbilical ligament. ]

   _The liver._—The right lobe was alone
visible. This extended entirely across
the right hypochondriac and epigastric
regions. Its external free border was
not in contact with the ribs. Between it
and the external abdominal wall there
was an interval of nearly an inch at its
greatest part, which was crossed by the
external lateral ligament. The inferior
border of the lobe rested upon and
nearly concealed the pylorus of the
stomach as well as the upper half of
right kidney. Corresponding in position
to the upper portion of the right kidney
was a well-defined layer of peritoneum,
presenting a sharply defined internal
border. Upon dissecting away the
peritoneum from this border it was found
to answer to the inferior vena cava. The
lesser omentum occupied its usual
position. The fundus of the gall-bladder
was two-thirds of an inch beyond the
anterior border of the lobe, immediately
to the outer side of the caudal lobe.
The position of the longitudinal fissure
was well off to the left side of the
abdomen, presenting, between the right
and left lobes, a conspicuous cleft
which was partially occupied by the base
of the caudal lobe. The round ligament,
with its associated suspensory ligament,
had doubtless passed nearly vertically,
before the relations had been disturbed
by the incision in the abdominal wall,
upwards and forwards to the anterior
abdominal wall at a point lying one inch
to the outer side of the centre of the
umbilicus.

   In the subject, as it lay on the
table with the flap _a, b_ (Fig. 2),
turned to the left, the suspensory
ligament had the appearance of being
much more obliquely inclined to the
left, and could be made nearly
horizontal by a little traction. Lying
beneath this ligament, but belonging to
the anterior abdominal wall, was a large
mass of subperitoneal fat about the size
of a pigeon’s egg. Extending to the
extreme left, and continuous with the
anterior border of the left lobe of the
liver, was a delicate prolongation of
liver substance which was lost within
the connecting band.

   [Illustration Figure 7:

   Fig. 7.   The abdominal organs of
Chang in position—the small
intestines removed.

   A.   Left lobe of liver.

   B.   Right lobe of liver.

   C.   Gall-bladder.

   D.   Suspensory ligament.

   E.   Lobules of fat in the position
of the termination of the
umbilical ligament. ]

   The upper surface of this
prolongation was supported by a fold of
peritoneum, extending directly upward,
apparently attached to the base of the
ensiform cartilage. Visible upon the
anterior aspect of this fold was a
tortuous artery, afterwards found to be
the left internal mammary. This fold may
be called _the accessory suspensory
ligament_; nothing similar to it was
seen in Chang. The left lobe of the
liver, save a portion of its anterior
edge, was not visible.

   In Chang (Fig. 7), by exposing the
parts as in Eng, throwing the abdominal
flap, _c, d_ (Fig. 2), to the right,
there was at once brought into view the
transverse colon, the greater omentum,
and greater curvature of the stomach.
The latter organ was large, empty, and
without any undue traction could be so
displayed as to yield its fundus and
greater curvature in position. The
fundus was not visible. Lying
conspicuously within the left
hypochondriac region was the spleen. Its
inferior free border, with its
peritoneal attachment, was distinctly
seen; its upper portions, however, were
invisible. The left lobe of the liver
held a position answering to that of the
right lobe in Eng—the external lateral
ligament being stretched across the left
hypochondriac region, pursuing a similar
course to the external lateral ligament
of Eng (_q. v._). The left lobe at its
outer portion rested upon the spleen,
its inner portion upon the stomach. The
outer portion of the left lobe presented
a thin compressed border, the inner
portion was divided by a deep sulcus
into two lobes.

   The right lobe lay deep within the
right hypochondriac region, the portion
about the longitudinal fissure
anteriorly, alone appearing in the
dissection. The suspensory ligament held
a position similar to that in Eng. The
gall-bladder held its normal position to
the right lobe, and was moderately
distended with bile.

   Both Chang and Eng had the organs
occupying the hypochondriac and
epigastric regions retaining, on the
whole, such relations as are usually
observed.

   This statement appears pertinent, at
this stage of the autopsy, in order to
explain—

   V. Interior of Band.

   We here describe (1) _the hepatic
pouches_; (2) _the umbilical pouches_;
(3) _the vascular structures of the
band_; (4) _the diaphragms_; (5) _the
ensiform cartilages_.

   1. _The hepatic pouches._—The
photograph (Fig. 2) indicates the
position of the right lobe of Eng’s
liver in the right hypochondriac region.
The right lobe of Chang is of course not
seen in the figure, since it lies on the
side of the body which is not in the
field of vision. It must follow from the
rights and lefts of the two individuals
being opposites that, in drawing a line
between the livers (which, as already
seen, occupy normal positions as to
right and left) across the band, such a
line will be diagonal to the axes of the
ensiform cartilages; Chang’s half of the
band having the line enter the band from
his “right,” Eng from his “left.” It
will also follow that any pouches of
peritoneum which might accompany this
line will pursue a similar direction—be
on the same plane—be right or left with
respect to the axis of that plane. Now
it was actually demonstrated that such a
line did extend between the livers, and
was accompanied by such peritoneal
pouches. These pouches were termed the
hepatic pouches, and may be described as
follows:—

   Chang.—The subject lying on the table
with rights and lefts determined as in
the acquired position, the finger could
be inserted behind the suspensory
ligament (Fig. 7) in a pouch lying
directly beneath the ensiform
cartilages, into which passed an
extension of liver-like tissue.

   Eng.—This fact could not be well
demonstrated in Eng in this position,
but is well seen in Fig. 8.

   It follows that the two hepatic
pouches are on nearly the same plane,
and that each approaches the central
point of the band diagonally from the
right side of the subject with whose
abdominal cavity it is continuous.

   2. _The umbilical pouches._—Beneath
the hepatic pouches, and between them
and the inferior border of the band,
were two pouches which, from their
association with the round ligament,
have been termed _the umbilical
pouches_.

   When the finger was passed toward the
band from the abdomen of Chang, and
following the peritoneum of the anterior
wall of the abdomen, it passed into a
pouch of the band directly over the skin
covering, across the band, over the
umbilicus, and was received within the
folds of the suspensory ligament of the
liver of Eng. This pouch was so
superficial that while the finger was in
the pouch any motion of the finger was
readily followed by the observer.

   In the same way as above, if the
finger was introduced _behind_ the
suspensory ligament of Eng, it slipped
into a pouch which passed across the
median line of the band, and was
received within the folds of the
suspensory ligament of the liver of
Chang.

   There were then two pouches
communicating with the two abdominal
cavities, arranged one above another in
the band, Chang’s being the lower of the
two. No remains of an umbilical vein
were detected, nor was there any
communication between the pouches and
the umbilicus. It has already been
noticed that the round ligament of each
liver passed from the longitudinal
fissure to a scar on the anterior wall
of the abdomen near the band. It was
not, therefore, within the round
ligaments, but the folds of the
suspensory ligaments, that the pouches
were found.

   Eng’s pouch measured 2-1/2 in. From
edge of Chang’s suspensory ligament to
end of hepatic pouch measured 3 in.

   Extending across the band, about
midway between the properties of the two
individuals, was a septum. It was
attached above and below to the
respective boundaries of the band, and
along its entire length was incorporated
with its two peritoneal cavities, so
that when in the course of the
dissection of the “posterior” surface of
the band the peritoneal covering of the
band was displayed, several large
lobules of fat were seen lying to Eng’s
side of the septum.[4]

   -----

   Footnote 4:

   Before the septum was known to exist,
the band was opened from behind   in the
presence of the Fellows of the College
(Feb. 18th, 1874). The   exact relations
of the septum could not at that time be
determined.   Figs. 8, 9, and 10 are
taken from studies of the parts made the
day   after the meeting.

   -----

   It will be seen that Fig. 8
represents the band opened to display
the pouches with the septum. The lower
end of the septum is fixed near the scar
of the umbilicus, and holds an immobile
position over the umbilical pouches. At
this point it is free from fat. But as
it extends over the hepatic pouches it
is more pliant. This portion of the
septum has been carried a little to
Chang’s side of the band to display the
entire length of the hepatic pouch of
Eng.

   Figs. 9 and 10 are designed to
exhibit the appearances presented in
securing views of the septum from its
sides. Fig. 9 is the side toward Chang,
and Fig. 10 is the side toward Eng.

   [Illustration Figure 8:

   Fig. 8.   The surface, C. R., E. L.,
showing the interior of band by
free division of the aponeuroses seen in
Fig. 7, and their             underlying
peritoneal attachments.

   A.   The orifice of umbilical pouch
of Eng.

   B.   The orifice of umbilical pouch
of Chang, showing connection
with suspensory ligament of Eng.

   C.   The fenestrated umbilical pouch
of Eng passing between the
folds of the suspensory ligament of
Chang.

   D.   Suspensory ligament of liver of
Eng.

   E.   Hepatic tract.

   F.   Hepatic pouch of Eng.

   G.   The septum. ]

   The pouches and septum were now
removed and the position of the hepatic
tract determined. It rested upon the
incurved borders of the ensiform
cartilages (see Fig. 15), and as the
subject lay on the table with the
“posterior” surfaces of the band exposed
(Fig. 11) the hepatic tract was slightly
arched. It measured three inches in
length, was compressed, and measured six
lines wide and three lines thick. The
tract arose from the livers at the same
point—namely, directly above the
longitudinal fissure, having more
fulness on the side of the right than of
the left lobe. The round ligament, as it
passed out of the longitudinal fissure
of each liver, was placed beneath and a
little to the left of the tract.

   [Illustration Figure 9:

   Fig. 9.   The septum viewed from
Chang’s side.

   A.   The orifice of umbilical pouch
of Chang.

   B.   The orifice of the hepatic pouch
of Chang.

   C.   Suspensory ligament of Chang
containing umbilical pouch of
Eng. ]

   [Illustration Figure 10:

   Fig. 10.   The septum viewed from
Eng’s side.

   A.   The orifice of the umbilical
pouch of Eng.

   B.   The orifice of the hepatic pouch
of same.

   C.   Suspensory ligament of Eng
containing the umbilical pouch of
Chang. ]

   3. _The vascular structures of the
band_ were as follows:—

   The livers being united, it was found
that a colored injection thrown into the
portal vein of Chang passed into the
liver of Eng. A careful dissection of
the blood vessel (Fig. 11, C) proved it
to be a terminal twig of the portal
system of Chang. It was of the thickness
of a No. seven catheter, French scale,
gradually diminished in size, and was
lost toward the centre of the band. It
did not pass as such across the band,
but appeared to break up into minute
branches before reaching the liver of
Eng. At the same time there was
undoubted distension of the portal
capillaries with the colored fluid under
the capsule of the dorsal surface of the
right lobe of Eng’s liver, one and one-
half inches from the band. Examination
of the branches of the mesenteric veins
of Eng revealed the curious fact that
some of them had received the injection.
This had not been transmitted through
the liver, for the portal vein at the
transverse fissure was empty, but
through a distinct extra-hepatic portal
track, which was found lying under the
peritoneum beneath the position of the
hepatic pouches, and in association with
the umbilical pouches. This vessel began
by relatively large radicals towards
Chang’s side, became larger as these
encroached on Eng’s side, and was
finally received within the portal
system of Eng’s body, as a tributary to
its mesenteric vein.

   [Illustration Figure 11:

   Fig. 11.   The surface, C. R., E. L.,
with pouches removed to display
the hepatic tract.

   A.   Liver of Chang.

   B.   Liver of Eng.

   C.   Portal vessel of Chang.

   D, D.   Minute branches of hepatic
artery.

   E.   Subcutaneous fat of surface, E.
R., C. L. ]

   No other vessels were met with in the
band excepting a few insignificant
branches of the hepatic artery, and the
terminal twigs of the right internal
mammary of Eng. The former vessels are
marked D, D, Fig. 11. The latter vessel
terminated by piercing the diaphragm,
and giving ultimate filaments to the
integument of the “front” of the band as
shown in Fig. 12.

   [Illustration Figure 12:

   Fig. 12.   The surface, C. R., E. L.,
with pouches, hepatic tract, and
peritoneal attachments removed to
display the diaphragms.

   A.   Subcutaneous fat of surface, E.
R., C. L.

   B, C.   Symmetrical muscular
fasciculi.

   D.   Fasciculi of Eng crossing the
median line of the band. ]

   4. _The diaphragms._—The subject
being in the same position as in Fig. 2,
the livers were removed, the peritoneal
coverings dissected from the band, and
the diaphragms exposed (Fig. 12). The
point (A), marked by the terminal twigs
of the right internal mammary of Eng,
indicated the “anterior” of the band. A
broad slip of fibres of Chang (B) was
seen to pass across the median line, and
to be inserted into the left border of
the ensiform cartilage of Eng (Fig. 17).
This arrangement would appear to
correspond to the smaller collection of
fibres (C) belonging entirely to Eng. A
second arrangement of fibres was seen
above those just indicated, immediately
under the cartilages (D). This appeared
to arise from the border of the
cordiform tendon of Eng by two distinct
narrow slips, which crossed the median
line to be inserted dispersedly on the
diaphragm of Chang.

   [Illustration Figure 13:

   Fig. 13.   The peritoneal linings of
the anterior walls of both
abdominal cavities.

   A, A.   The summits of the bladders.

   B, B.   The umbilical ligaments.

   C, C.   The nodules of fat at the
parietal scar.

   D, D.   The isolated lobules of fat.
]

   5. _The ensiform cartilages._—After
removing the diaphragms the cartilages
were exposed. They may be described as
follows:—

   Chang.—The cartilage measured 2-1/2
in. wide, and 8 in. in length along its
axis. The right border was very
prominent, and projected 1/2 in. beyond
the limit of the corresponding border in
Eng. It was almost in close contact with
the cartilage of the eighth rib; it was
very robust, with upper surface convex,
under surface nearly plane. The left
lateral border was 2-1/2 in. in length,
right lateral border 11 lines in length.
The former was marked by three tubercles
of about equal size. One situated about
1 in. from the sternal origin; the other
about 2 in. from the same point; the
third at its extreme anterior border.
None of these were robust, or presented
any of the thickening noticed on the
right side. The middle of these
tubercles was on a line with that of the
posterior tubercle. The junction of the
ensiform process with the sternum was
not marked by the eminence
characterizing the similar point in Eng.

   Eng.—The cartilage differed from that
of Chang in being 2-1/3 in. wide, 11
lines in length of axis. The left
lateral border was abruptly deflected
downward, and did not present the
transverse smooth projection noticed in
Chang. This deflection was almost at
right angles to the dorsal surface,
acuminate inferiorly, and presenting a
straight surface toward Chang, and an
oblique one toward the ribs. The length
of left lateral border was 1 in. The
right lateral border, 1-1/3 in. in
length, presented a smooth sub-rounded
edge without tubercles, and terminated
in a free rounded border on a plane a
little above that of Chang. On the whole
this border was more robust than that of
Chang. On the dorsal aspect of the
process near its base was seen the
rounded eminence described in the
account of the external appearances (see
page 7).

   A comparison between the two ensiform
cartilages shows that in Chang the
anterior border was longer than in the
right in Eng. In other proportions Eng’s
was equal if not larger than Chang’s,
and was more robust.

   [Illustration Figure 14:

   Fig. 14.   A section of both ensiform
cartilages, C. R., E. L.

   A.   Chang’s cartilage.

   B.   Eng’s cartilage.

   C.   The synchondrosis.

   D.   The bursa-like sac covering the
same.

   E.   An opening in the sac.

   F.   Transversalis muscle of Eng.

   G.   Transversalis muscle of Chang. ]

   The union between the cartilages was
of the character of a symphysis. The
union was very intimate along the border
E. L., C. R., “posterior” (Fig. 14); the
exposure of the junction by a delicate
transverse cut showed a close union
between the cartilages, thus
constituting this part of the band a
synchondrosis. That this, however, did
not characterize the entire line of
apposition was at once seen by turning
to the border E. R., C. L. (“anterior”),
where an interval, two lines in width,
was seen between the cartilages, an
interval which had been evidently
susceptible of variation during life.
This interval extended across one-fourth
the width of the band. The portion of
the band between the parts as above
indicated, was occupied by a bursa-like
sac (Fig. 14, D), which was opened by a
minute orifice (E) to display its true
nature. This sac was crossed above by a
stout band of fibrous tissue (Fig. 15,
A) an inch in width. Beneath, the sac
was protected by a less well-defined
band of the same width as the upper
ligament, and which crossed between the
two processes, to be lost in the
perichondrium.

   [Illustration Figure 15:

   Fig. 15.   Upper surface of ensiform
cartilages.

   A.   The upper ligament uniting the
cartilages. ]

   Viewing the cartilages as the
constituent parts of the band, we found
the border C. L., E. R., the “anterior,”
to be longer than C. R., E. L., the
“posterior.” C. L., E. R. was a convex,
nearly even border, C. L. being larger
than E. R., with a gaping interval
placed nearer Eng than Chang. C. R., E.
L. was an irregular, uneven border,
without interval, C. R. being smaller
than E. L., and placed to the outer
side.

   VI. Other Structures.

   1. _The spleens._—This organ in Eng
was 5 in. long, 3-1/3 in. wide. The
dorsum was marked by a large sulcus,
extending nearly across the organ,
continuous with the sulcus on the
superior border. The hilus was
relatively shorter than that of Chang,
beginning above, fully an inch below its
upper border, and terminating within a
half inch of its inferior border.

   In Chang it measured 5 in. long,
2-1/3 in. wide. It was sub-elliptical in
form, upper lip somewhat abruptly
compressed. The lower border was obtuse
and rounded. The dorsum was smooth, and
presented at its posterior edge a single
sulcus placed midway between the tip and
the inferior border. The hilus extended
nearly the entire length of the under
surface.

   2. _The livers_ (Fig. 16).—In Eng the
liver was 9 in. broad. The right lobe
was 7-1/2 in. wide, antero-posteriorly.
The fundus of the gall-bladder was seen
on the anterior edge of the organ. The
only noticeable feature on the under
surface of the liver, was the lobus
Spigelii. This was large, measuring 2
in. in transverse diameter, and 2-1/3
in. in antero-posterior diameter. It
presented a somewhat increased breadth
of neck, which was overlapped by an
anterior prolongation of the lobe, and
terminated by a rounded compressed
extremity at the transverse fissure. The
quadrilateral lobe was well developed, 2
in. long in greatest diameter, 10 lines
wide.

   [Illustration Figure 16:

   Fig. 16.   The livers.

   A.   Right lobe of Eng.

   B.   Left lobe of same.

   C.   Right lobe of Chang.

   D.   Left lobe of same.

   E.   Hepatic tract.

   F.   Round ligament of Eng.

   G.   Round ligament of Chang.

   H.   Accessory suspensory ligament of
Eng, with termination of             the
right mammary artery.

   I.   Fundus of gall-bladder of Chang.

   J.   Fundus of gall-bladder of Eng. ]

   In Chang the liver was 8-1/3 in.
broad. The right lobe was 5 in. wide,
antero-posteriorly. The appearance of
the gall-bladder corresponded to that
seen in Eng. The under surface was
normal. The lobus Spigelii presented a
narrower neck than in Eng, the anterior
prolongation being greater. The
quadrilateral lobe was less developed
than in Eng. Indeed it was not raised
above the under surface of the right
lobe, and its limits were so imperfectly
marked that it could not well be
measured.

   [Illustration Figure 17:

   Fig. 17.   Kidneys of Eng.

   A.   Left kidney.

   B.   Right kidney.

   C.   Left renal vein.

   D.   Left supra-renal vein.

   E.   Left spermatic vein.

   F.   Descending vena cava not
distended with clot.

   G.   Right renal vein.

   H.   Aorta distended with plaster.

   I.   Primitive iliac arteries. ]

   3. _The kidneys._—In Eng, the body
lying on the table E. R., C. L., the
left kidney (Fig. 17, A) was 4 in. long,
1-1/2 wide at its hilus, and of the
usual kidney shape. It lacked 1/2 in. of
reaching the crest of the ilium. The
renal vein (Fig. 17, C) of the same side
measured 3 in. in length, and was
decidedly oblique in position, its
termination in the cava being below the
level of the lower end of the kidney.

   The right kidney (Fig. 17, B)
corresponded in position to the left
kidney of Chang, that is to say, it was
in the shallower portion of the abdomen,
and in contact with the abdominal wall.
It measured 4 in. in length, and 2-1/4
in. in width. Its inferior border lacked
2 in. of reaching the superior crest of
the ilium. The renal vein ascended a
little upward to enter the cava a little
below the level of the upper end of the
kidney.

   In Chang, the body lying in such a
way that the great trochanter of the
right side rested on the table, the left
trochanter being raised three inches
from the same plane, an obliquity was
given to the trunk, and rendered the
position of the abdominal organs
somewhat anomalous.

   The left kidney (Fig. 18, A) lay with
its lower half clearly within the iliac
fossa, its inferior border answering to
a point an inch and a half below the
termination of the aorta. The organ lay,
at its inner and inferior portion, upon
the left primitive iliac vein; it
measured 3-3/4 in. in length, and 2-7/12
in. in width at its widest part. It was
larger below, where it retained the
usual appearance, but was somewhat
abruptly pointed above, and was marked
by the characteristic notch on its inner
side. The renal vein (Fig. 18, C) was
very obliquely situated, indeed was
almost parallel with the cava, and was
3-1/2 in. long. The termination of the
renal vein answered to a line running
across the abdomen lying fully 1 in.
above the upper end of the left kidney.

   [Illustration Figure 18:

   Fig. 18.   Kidneys of Chang.

   A.   Left kidney.

   B.   Right kidney.

   C.   Left renal vein.

   D.   Right renal vein.

   E.   Left spermatic vein.

   F.   Aorta filled with plaster.

   G.   Primitive iliac veins.

   H.   Descending cava distended with
clot.

   I.   Left supra-renal vein. ]

   The right kidney (Fig. 18, B) was
normally situated. It measured 4 in. in
length, and 1-1/2 in. in width at its
centre, and presented the usual reniform
appearance. Its inferior edge just
reached an eminence answering to the
superior crest of the ilium.

   4. _The testicles._—The right
testicle of Eng was normal. The left
testicle was not within the scrotum.
Dissection from within the abdomen
showed that the organ had been
retracted. It lay well concealed within
the inguinal canal, slight traction
making it appear within the abdomen.

   The testicles of Chang were normal.

   5. _The hearts._—The heart in Eng was
situated nearer the median line than
normal. The abdominal incision was very
unfavorable for studying its exact
position in the mediastinum. It was
removed through an opening made in the
diaphragm. The right side of the heart
was occupied by a soft grumous clot much
smaller than was found in the same
locality in Chang, and which did not
distend the cavities. The left side was
normal. It was without clot so far as
could be determined in the injected
condition of the ventricle.

   The heart of Chang presented a right
auricle and ventricle distended with a
dense venous clot; this extended from
the right ventricle along the pulmonary
arteries. The left side of the heart was
empty.

   The ductus arteriosus and foramen
ovale were firmly closed in both hearts.

   6. _The vessels._—The arteries of
both subjects were, so far as examined,
in an extremely atheromatous condition.
Large plates of calcareous matter were
deposited in the abdominal aortas. The
injecting matter flowed insufficiently
in the left lower extremity of Chang,
from a clot plugging the femoral artery.

   The venous system of Chang was
engorged, giving the appearance of these
vessels having been injected after
death; that of Eng was comparatively
empty.

   7. _The lungs._—The lungs were so
altered by _post-mortem_ changes prior
to embalming, their contraction by the
chloride of zinc, and their increase of
weight from the plaster, that no
extended examination was made of them.
But little difference was seen between
the conditions of the lungs in the two
men. No hepatization was present in
Chang.

   8. _The vertebral column and
ribs._—There was marked lateral
curvature of the vertebral column in
both bodies. This was more conspicuous
in Chang. The convexity of the curve was
about half-way down the vertebral
column, and inclined in Chang to the
right side. The distance from the centre
of the vertebral column to the left
abdominal wall, 2 in.; to the right
abdominal wall, 5 in. The left side of
the abdominal cavity, measuring from
about the level of the band to the last
rib of the right side, 7-1/2 inches.

   The ribs in both Chang and Eng were
22 in number, 7 true and 4 false. On the
right side of Eng the first, second, and
third ribs were normal. The fourth,
fifth, sixth, and seventh presented
diminished intercostal spaces, owing
probably to the extreme traction made on
them by the deflection of the ensiform
cartilages. The intercostal space
between the third and fourth ribs was
slightly contracted; that between the
fourth and fifth ribs was very much
contracted, the muscle being bulged
inward. Between the fifth and sixth, and
sixth and seventh ribs the space was
less contracted. The remaining
intercostal spaces were about normal.
The fifth rib near its articulation with
the vertebral column formed a well-
defined ridge within the thorax,
carrying with it the sixth and seventh
ribs, thus forming a rounded elevation,
distinguishing the positions of these
ribs from the thoracic wall above and
below this point, where the parietal
surface presented the usual concave
appearance.

   On the left side of Chang a similar
arrangement of ribs and intercostal
spaces was seen to the above.

   The remaining organs were not
examined.

   REMARKS.

   With reference to the cause of death
of the Siamese twins it may be briefly
said that, in consequence of the
restrictions by which we were bound, no
examination of the brains was made. It
cannot, therefore, be proved that the
cause of Chang’s death was a cerebral
clot, although such an opinion, from the
suddenness of death, preceded as it was
by hemiplegia and an immediate
engorgement of the left lung, is
tenable. Eng died, in all probability,
in a state of syncope induced by
fright—a view which the over-distended
bladder and the retraction of the right
testicle would appear to corroborate.

   The existence of lateral curvature
was not unsuspected. It was known to
those who had examined the twins before
death. Indeed, it must have been a
necessity of the acquired position.

   The presence of a pad of
subperitoneal fat at the usual position
of the umbilicus was certainly curious.
It would appear to be an example of a
localized nutritive change about the
peritoneum, at the centre of the
umbilical region, anticipating the exit
of the vessels of the cord at that
point. Familiar examples of this
anticipation between structures
developing from different layers of the
embryo are seen in malformations of the
genital organs, eye, ear, etc. In the
above example it is remarkable only from
the rarity of the conditions yielding
it.

   The circulation in each individual of
the twins was practically complete,
since the demonstration of continuity
between the portal systems, although
satisfactory, invites the conclusion
that the amount of blood which passed
from one to the other side of the band
must have been, in the condition of the
parts at the time of the demonstration,
very inconsiderable, and was not
competent in all probability to modify
the performance of any act of the
economy.

   In the fœtal and early period of
extra-uterine life the vessels must have
been more capacious, and associated with
a large tract of liver tissue. It
follows, all things being equal, that an
attempt at division of the band in early
life would have been accompanied with
more venous hemorrhage than at any
subsequent period.

   In proof that the twins were the
product of a single conception, the
strict correspondence between the
markings of the two spleens, as well as
the number of the ribs, may be observed.
The absence of available data bearing
upon the question of symmetry between
visceral organs of twins, prevents us
from drawing here too positive an
inference. It is probable, however, that
the twins were individuals of a single
organism, remarkable for its complete
expression of duplex bilaterality.[5]

   -----

   Footnote 5:

   I desire to return thanks to Dr. T.
H. Andrews and Dr. J. W. White,   Jr.,
for important assistance rendered in
preparing the notes of the   autopsy.

   -----

   [Illustration Figure 19:

   Fig. 19.   Foreshortened view of the
trunks, showing in the acquired
position the band from above and the
contours of its             lateral
surfaces. ]

   DESCRIPTION OF FIGURES.

   FROM PHOTOGRAPHS.

   Fig. 1. Twins in acquired position
(E. R., C. L.). Taken in St.
Petersburg, 1870.  Page 3.

   Fig. 2. Twins in acquired position
(E. R., C. L.). Taken after death
at Philadelphia.  Page 8.

   FROM SKETCHES.

   Fig. 3. The surface, C. R., E. L.,
exposed by removal of skin and
superficial fascia to display the
tendons of the external
oblique muscles and adjacent parts.
Page 12.

   A. The superficial fascia—lost over
the position of Chang’s
umbilical pouch.

   B, C. Supplemental layers of fibrous
tissue of Eng not seen in
Chang; B is a continuation toward Eng of
aponeurotic fibres           having a
source from the linea alba of Chang;
C is independent of the former, and is
continuous with the           deep
pectoral fascia.

   D. The interlacing of fibres on
tendon of external oblique muscle
of Chang.

   E. The linea alba of Chang, beginning
at C. R.

   F. Its continuation to E. L., and
insertion upon the ensiform
cartilage.

   Fig. 4. The umbilical ligament in
Eng.  Page 15.

   A. The umbilical ligament.

   B. The lobule of fat at position of
normal umbilicus.

   Fig. 5. The umbilical ligament in
Chang.  Page 16.               The
letters as in Fig. 4.

   Fig. 6. The abdominal organs of
Eng—the small intestines removed.
Page 17.

   A. Left lobe of liver.

   B. Right lobe of liver.

   C. Gall-bladder.

   D. Suspensory ligament.

   E. Lobules of fat in the position of
the termination of the
umbilical ligament.

   Fig. 7. The abdominal organs in
Chang—the small intestines removed.
Page 19.     The letters as in Fig. 6.

   Fig. 8. The surface, C. R., E. L.,
showing the interior of band by
free division of the aponeuroses seen in
Fig. 7, and their           underlying
peritoneal attachments.  Page 24.

   A. The orifice of umbilical pouch of
Eng.

   B. The orifice of umbilical pouch of
Chang, showing connection           with
suspensory ligament of Eng.

   C. The fenestrated umbilical pouch of
Eng passing between the           folds
of the suspensory ligament of Chang.

   D. Suspensory ligament of liver of
Eng.

   E. Hepatic tract.

   F. Hepatic pouch of Eng.

   G. The septum.

   Fig. 9. The septum viewed from
Chang’s side.  Page 25.

   A. The orifice of umbilical pouch of
Chang.

   B. The orifice of hepatic pouch of
Chang.

   C. Suspensory ligament of Chang,
containing umbilical pouch of
Eng.

   Fig. 10. The septum viewed from Eng’s
side.  Page 26.

   A. The orifice of umbilical pouch of
Eng.

   B. The orifice of hepatic pouch of
Eng.

   C. Suspensory ligament of Eng,
containing umbilical pouch of
Chang.

   Fig. 11. The surface, C. R., E. L.,
with pouches removed to display the
hepatic tract.  Page 27.

   A. Liver of Chang.

   B. Liver of Eng.

   C. Portal vessel of Chang.

   D, D. Minute branches of hepatic
artery.

   E. Subcutaneous fat of surface, E.
R., C. L.

   Fig. 12. The surface, C. R., E. L.,
with pouches, hepatic tract, and
peritoneal attachments removed to
display the diaphragms.           Page
28.

   A. Subcutaneous fat of surface, E.
R., C. L.

   B, C. Symmetrical muscular fasciculi.

   D. Fasciculi of Eng, crossing median
line of band.

   Fig. 13. The peritoneal linings of
the anterior walls of both abdominal
cavities.  Page 29.

   A, A. The summits of the bladders.

   B, B. The umbilical ligaments.

   C, C. The nodules of fat at the
parietal scar.

   D, D. The isolated lobules of fat.

   Fig. 14. A section of both ensiform
cartilages, C. R., E. L.  Page 31.

   A. Chang’s cartilage.

   B. Eng’s cartilage.

   C. The synchondrosis.

   D. The bursa-like sac covering the
same.

   E. An opening into the sac.

   F. Transversalis muscle of Eng.

   G. Transversalis muscle of Chang.

   Fig. 15. Upper surface of ensiform
cartilages.  Page 32.

   A. The upper ligament uniting the
cartilages.

   Fig. 16. The livers.  Page 34.

   A. Right lobe of Eng.

   B. Left lobe of same.

   C. Right lobe of Chang.

   D. Left lobe of same.

   E. Hepatic tract.

   F. Round ligament of Eng.

   G. Round ligament of Chang.

   H. Accessory suspensory ligament of
Eng, with termination of the
right mammary artery.

   I. Fundus of gall-bladder of Chang.

   J. Fundus of gall-bladder of Eng.

   Fig. 17. Kidneys of Eng.  Page 35.

   A. Left kidney.

   B. Right kidney.

   C. Left renal vein.

   D. Left supra-renal vein.

   E. Left spermatic vein.

   F. Descending vena cava not distended
with clot.

   G. Right renal vein.

   H. Aorta distended with plaster.

   I. Primitive iliac arteries.

   Fig. 18. Kidneys of Chang.  Page 37.

   A. Left kidney.

   B. Right kidney.

   C. Left renal vein.

   D. Right renal vein.

   E. Left spermatic vein.

   F. Aorta filled with plaster.

   G. Primitive iliac veins.

   H. Descending cava distended with
clot.

   I. Left supra-renal vein.

   Fig. 19. Foreshortened view of the
trunks, showing in the acquired
position the band from above, and the
contours of its lateral
surfaces.  Page 42.

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   Transcriber’s notes:

   ● The errors deemed most likely to be
the printer’s have been       corrected,
and are noted here.     ● Where
hyphenation occurs on a line break, the
decision to retain       or remove is
based on occurrences elsewhere in the
text.     ● Errors in punctuation and
quotes have been silently restored.
● Illustrations have been moved to the
corresponding paragraph.     ● The
footnotes were moved to near the
corresponding paragraph.     ● The
numbers below reference the page and
line in the original       book.

   reference  correction      original
text     86.36    abruptly        but
was somewhat abruptedly pointed
26.4    blood vessel    A careful
dissection of the bloodvessel

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---------------------------

   *** END OF THE PROJECT GUTENBERG
EBOOK 68165 ***