Oskar Kobyliński (1856-1926) and the first description of Noonan syndrome in the medical literature

While a student of University in Dorpat (now Tartu, Estonia) Oskar Kobyliński published an article reporting on his 22-year-old patient Leisar Eischikmann, who suffered from a congenital deformity of the neck. Kobyliński described this rare anomaly and called it "flüghautige Verbreitung des Halses" (wing-like extension of the neck). It was only in 1902 when the name pterygium colli was introduced, and it has been in use ever since. This malformation is part of some congenital syndromes, most prominently, Turner syndrome and, more rarely, of Noonan syndrome. As Opitz et al. pointed out, the patient described in the 1883 article from Archiv für Anthropologie is probably the first person with Noonan syndrome to have been pictured in the medical literature. The article was signed only by "O. v. Kobylinski, student of medicine." Further archival research was needed to identify this physician and provide more details about his unusual career.

Microcephalic osteodysplastic primordial dwarfism, with the fascinating history of "Mademoiselle Crachami"

This review critically examines the findings which characterize the dysmorphic, radiologic and behavioral phenotype of Microcephalic Osteodysplastic Primordial Dwarfism (MOPD) and has an historical perspective on it. MOPD is a group of primordial dwarfism syndromes with prenatal onset growth retardation, a typical craniofacial appearance and behavioral phenotype. In 1959, Mann and Russell have described the first case in a detailed report, and named "microcephalic midget of extreme type". In their report; based on historical records and a small painting, they pointed "Mademoiselle Crachami" as the oldest known case.

Klippel-Feil syndrome with other associated anomalies in a medieval Portuguese skeleton (13th-15th century)

Klippel-Feil syndrome, or synostosis of the cervical spine, is the result of an abnormal division of somites during embryonic development. This report analyses an adult male (exhumed from a Portuguese graveyard dating from the 13th to the 15th century) with malformations in the cranium and vertebral column. Besides the lesions that are typical of Klippel-Feil syndrome type II, other defects usually linked to this pathology are described (occipito-atlantal fusion, hemivertebrae, butterfly vertebrae, cervical rib, changes in normal number of vertebral segments and a possible Sprengel deformity).

The Helena syndromes

The author gives a personal account on how he was introduced to the field of clinical genetics as a student of John Opitz in Helena, MT. That process was facilitated by the study of several malformation syndromes. Particularly instructive were the approaches to the cardio-facio-cutaneous, the Perlman, and the FG syndrome. These three conditions are briefly revisited with a critical perspective, made possible by the elapse of 20 years, since the time when the author became acquainted with them.

Meckel on developmental pathology

Before Schleiden and Schwann, Darwin and Mendel there passed briefly a towering giant, Johann Friedrich Meckel the Younger (1781-1833), now glimpsed only fleetingly and obscurely through the mist of time and former controversies, who can nowadays easily and clearly be identified as the father of a "pre-modern" developmental biology. At his beginning this prodigiously gifted physician-scholar had, as one would say nowadays, an unfair advantage, his cradle having been rocked, as it were, by the preparators in his father's and grandfather's huge collection of normal and abnormal anatomical "specimens" in the home in which he was born and raised including his father's own skeleton (with two anatomical anomalies!). Initially reluctant to follow in the steps of his illustrious anatomist/physician grandfather and father, he nevertheless early demonstrated extraordinary gifts in anatomy and zootomy. Napoleon's conquest of his homeland notwithstanding, Meckel spent at least 2 extremely fruitful years in Paris, under the tutelage of Cuvier, but also in close contact with Geoffroy St. Hilaire (Etienne), Lamarck, and von Humboldt. He not only translated Cuvier's Leçons d'anatomie comparée into German but also greatly enriched this pivotal treatise with observations of embryonic and malformed fetuses and animals only of passing interest to his mentor. In his numerous publications, Meckel was the first to relate abnormal to normal development, define anomalies of incomplete differentiation (vestigia), but, most importantly, to relate those malformations known in humans to those that are normal adult developmental states in "lower" animals (atavisms). Thus, Meckel's three-fold parallelism of the scala naturae, normal ontogeny, and the malformations in humans and animals makes him a recapitulationist par excellence, however, without ever venturing into a fully articulated and explicit theory of descent. Today Meckel is remembered solely as the discoverer of the syndrome and cartilage named after him, and as having interpreted, correctly, the developmental nature of the "Meckel" diverticulum. It is virtually unknown that Meckel also first enuntiated the concept and distinction between primary and secondary malformations/anomalies, introduced the notion of heredity into the causal analysis of congenital anomalies, was the father of syndromology (the Meckel syndrome), had a clear understanding of pleiotropy and heterogeneity, and can unequivocally be regarded as the father of developmental pathology. In hindsight, and inspite of much professional success, Meckel emerges as a tragic figure in the history of biology, his life cut short at 52 without an ability to incorporate cell theory and the embryological insights of his younger contemporaries into his intellectual edifice which might have made it possible for him to finally and clearly see "analogy" (now homology), of which he was the greatest expert in his era, as incontrovertible evidence for descent. In that case, Darwin and Haeckel might have even had the courtesy of a tip-of-the-hat in Meckel's direction.

Broad thumb-hallux (Rubinstein-Taybi) syndrome 1957-1988

This presentation records the early history of the description of the broad thumb-hallux syndrome and attempts to update the current state of knowledge about this syndrome. Information was collected and reviewed on 571 individuals from the world literature, from communications with colleagues and families of affected individuals, and from personal observation. The diagnosis was established in most cases by confirming the concurrence of the constellation of major diagnostic criteria, including broad short terminal phalanges of the thumbs and halluces, with or without angulation deformity; characteristic facial appearance with beaked or straight nose, antimongoloid slant of palpebral fissures, apparent or clinical hypertelorism and grimacing smile; stature and head circumference (OFC) below 50th centile; mental, motor, social, and language retardation; stiff awkward gait; and incomplete or delayed descent of testes in males. Information on associated clinical factors, familial occurrence, and cytogenetic findings is presented.

Acrofacial dysostosis (AFD) with preaxial limb hypoplasia (Nager AFD) and club foot diagnosed in a fetus from 1812 in the anatomical collections at the University of Halle, Germany

The Anatomical Collections of the Department of Anatomy and Cell Biology at the University of Halle, Germany, comprise more than 8,000 specimens, about 600 of them congenital anomalies. The collection of abnormal human and animal specimens began with the private collections of Johann Friedrich Meckel the Elder (1724-1774), his son Philipp Friedrich Theodor Meckel (1755-1803), and his grandson Johann Friedrich Meckel the Younger (1781-1833). Meckel the Younger founded the science of developmental pathology in Germany. Radiographical techniques, computer tomographic methods (CT), magnetic resonance imaging (MRI), and molecular cytogenetic techniques, for example, comparative genomic hybridization (CGH) were used to diagnose abnormal human fetuses in the Meckel Collection. On examination of one of the human fetuses, originally described by JF Meckel the Younger in 1812 or earlier, we found striking clinical manifestations including mandibulofacial defects and preaxially malformed limbs. With respect to external findings, we propose that the condition is acrofacial dysostosis (AFD) with preaxial limb hypoplasia (Nager AFD) in combination with club foot, tibial torsion, and single umbilical artery. We used genetic analyses to test whether the observed limb malformations could be caused by aneuploidy. CGH-ratio profiles of all chromosomes were apparently normal. It is likely that Meckel's specimen is the earliest known fetus with Nager AFD.

The embryology of conjoined twins

INTRODUCTION

Attention is drawn to the spontaneous incidence of twinning, both dizygotic and monozygotic in different mammalian species. Conjoined twinning, however, only arises when the twinning event occurs at about the primitive streak stage of development, at about 13-14 days after fertilisation in the human, and is exclusively associated with the monoamniotic monochorionic type of placentation. It is believed that the highest incidence of conjoined twinning is encountered in the human. While monozygotic twinning may be induced experimentally following exposure to a variety of agents, the mechanism of induction of spontaneous twinning in the human remains unknown. All agents that are capable of acting as a twinning stimulus are teratogenic, and probably act by interfering with the spindle apparatus.

DISCUSSION

The incidence of the various types of conjoined twinning is discussed. Information from the largest study to date indicates that the spontaneous incidence is about 10.25 per million births. The most common varieties encountered were thoraco-omphalopagus (28%), thoracopagus (18.5%), omphalopagus (10%), parasitic twins (10%) and craniopagus (6%). Of these, about 40% were stillborn, and 60% liveborn, although only about 25% of those that survived to birth lived long enough to be candidates for surgery. Conjoined twinning occurs by the incomplete splitting of the embryonic axis and, with the exception of parasitic conjoined twins, all are symmetrical and "the same parts are always united to the same parts". Fusion of monozygotic twins is no longer believed to be the basis of conjoined twinning. Accounts are provided of the anatomical features of each of the commonly encountered varieties.

The death of Alexander the Great--a spinal twist of fate

Alexander the Great died in 323 B.C. from an unknown cause. Physical depictions of this historical figure reveal the likelihood of a cervical scoliotic deformity. This is substantiated with the medical history and is correlated with his untimely death. For the first time, it is concluded that Alexander's death may have ensued from the sequelae of congenital scoliotic syndrome.

Features described and illustrated in 1684 suggesting Meckel-Gruber syndrome

In 1684, Mr. Christopher Krahe described a monstrous child, born in Denmark on Friday, February 29, 1684. The description is suggestive of a diagnosis of Meckel-Gruber syndrome (dysencephalia splanchnocystica). This may represent the oldest description and illustration of the syndrome, of which the first detailed description is attributed to Johann Friedrich der Jüngere in 1822.

Autopsy on a case of Roberts syndrome reported in 1672: the earliest description?

In 1672, François Bouchard reported the autopsy of a male infant discovered on public exhibition at Leiden. The findings of tetraphocomelia more severe in the upper limbs with reduction in the number and length of digits, hydrocephalus, bilateral cleft lip, micrognathia, and cryptorchidism are consistent with a diagnosis of Roberts syndrome. Bouchard did not find internal abnormalities other than hydrocephalus, which he attempted to demonstrate by showing decreased specific gravity of the brain. Death was due to umbilical vein hemorrhage following birth trauma.

[The conjoined twins born in Valdarno al Terraio]

Surgical pre and post-operative problems involving the separation of conjoined twins of ischiopagus type make actual the interpretation of a relief coming from the Hospital of Santa Maria della Scala in Florence and dating probably from XIVth century. The work has been sculptured after the death of a couple of ischiopagus twins in the same Hospital in 1316. Their birth is registered in Giovanni Villani's Cronaca and in Petrarca's Rerum Memorandarum Libri.

A 100-year-old anatomical specimen presenting with boomerang-like skeletal dysplasia: diagnostic strategies and outcome

The Museum Vrolik collection of human anatomy comprises 360 recently redescribed specimens with congenital anomalies. The specimen described here dated from 1881 and presented with a general embryonic appearance, disproportionate short stature, brachycephaly, widened cranial sutures, hypertelorism, microphthalmia, bilateral cleft lip and palate, micrognathia, short and curved limbs, polysyndactyly, and abnormal female genitalia. Conventional radiography was hampered by decalcification of the skeleton, due to acidification of the preservation fluid. The use of additional imaging techniques, i.e., mammography, computerized tomography with three-dimensional reconstruction, and magnetic resonance imaging eventually led us to conclude that the condition of our specimen was similar to Piepkorn type skeletal dysplasia, boomerang dysplasia, and a condition described by Carpenter and Hunter [1982: J Med Genet 19:311-315], though none of these diagnoses seemed fully applicable.

Windows on other worlds: the rise and fall of sideshow alley

This article explores the world of Sideshow Alley, which emerged from the ancient fair culture of Britain and took root in the agricultural show movement of Australia by the 1880s. There it flourished until the 1950s, when modernity and respectability caused its demise. The article also argues that Sideshow Alley was a place of power that helped to shape the identities of many Australians through the display of difference and that it also provided a site of agency for those displaying themselves.

Congenital anomalies in the teratological collection of Museum Vrolik in Amsterdam, The Netherlands. I: Syndromes with multiple congenital anomalies

The Museum Vrolik collection of the Department of Anatomy and Embryology of the University of Amsterdam, founded by Gerardus Vrolik (1775-1859) and his son Willem Vrolik (1801-1863), consists of more than 5,000 thousand specimens of human and animal anatomy, embryology, pathology, and congenital anomalies. Recently, the collection of congenital anomalies was recatalogued and redescribed according to contempory syndromological views. The original descriptions, as far as preserved, were compared with the clinical and radiographical findings. In 13 specimens the following multiple congenital anomalies (MCA) syndromes were diagnosed: acrofacial dysostosis, Apert syndrome, Brachmann-De Lange syndrome, ichthyosis congenita gravis, Jarcho-Levin syndrome, Meckel syndrome, oro-facio-digital syndrome type IV, Roberts syndrome, Smith-Lemli-Opitz syndrome, Treacher Collins syndrome, and trisomy 13. It appeared that the founders of the museum studied and described several of these syndromes many years before they became established as such. In some specimens a reliable diagnosis is still pending. The use of additional diagnostical techniques, such as MRI, CT scanning, and fluorescence in situ hybridization, in these specimens is currently being investigated.

Alice Vance ("Das Bärenweib"): a historical case of Nievergelt syndrome

Several malformed individuals were presented at the World Exhibition in Antwerp in 1894. Among them was Mrs. Alice Vance from Mount Pleasant, Texas, with congenital limb defects, and Mr. Eugen Berry, who had asymmetrical, monstrous enlargement and macrodactyly of the feet, i.e., Proteus syndrome. After the World Exhibition Mrs. Vance presented herself to the public in Castan's Panopticon imitating a bear. She became famous under the stage name "Das Bärenweib" ("the bear-like woman") and was examined by several German clinicians, and her malformations were considered to be of high scientific interest. Mrs. Vance had mesomelic dwarfism and her mother was known to have similar malformations. Her limb deficiencies were generally considered a unique congenital condition those days, and the diagnosis of "a maternally inherited malformation of the forearms and the shanks" [Daffner 1898: Munch Med Wochenschr 25:782] was made. Virchow [1897: Verh Berl Ges Ethnol Urgeschichte 29:624], feeling attacked by a daily newspaper stating that the physicians as well as the police of Berlin had missed the diagnosis of an "English disease," eventually exercised his authority and diagnosed Alice Vance as a "phocomelic." Clearly, she was not a phocomelic according to past and current definition of this term. Thus, from a historical point of view, the story illustrates how pressure from the daily press altered the definition of an up-to-then precisely defined medical term for decades. According to the clinical data and an X-ray report available from the literature, Alice Vance had a dominantly inherited type of mesomelic dwarfism. We propose the diagnosis of Nievergelt syndrome.

Tetraphocomelia and bilateral cleft lip in a historical case of Roberts syndrome [Virchow, 1898]

We discuss an unlabelled specimen of tetraphocomelia and bilaterally cleft lip from the former Virchow Museum of our Medical School. Identity of the subject with a case of what was later termed "Roberts syndrome" published by Rudolf Virchow in 1898 is demonstrated. Rediscovery of this important historical case is gratifying, since almost 95% of the specimens of Virchow's collection were lost during World War II. We have restudied Virchow's case. Recent CT scan images of the fetus are presented. We review data from the literature and present new clinical details. The fate of the original clinical data after passing through three reviews is documented briefly. We also reconstruct Virchow's view on phocomelia and its consequences for later research.

Earliest evidence for arthrogryposis multiplex congenita or Larsen syndrome?

A sixteenth-century illustrated pamphlet from Great Britain suggests that documentary evidence may permit accurate diagnosis of pathological conditions in earlier societies. The document is of particular importance, since the presented congenital abnormalities, including cleft lip, spina bifida cystica, genu recurvatum, and talipes deformity are reported rarely in archaeological skeletal material. It is suggested that the combination of abnormalities may represent the earliest case of arthrogryposis multiplex congenita or Larsen syndrome.

A philosophical approach to conjoined twins

There are increasing numbers of attempts to surgically separate conjoined twins. Almost every type of conjoined twins have been separated, with varying results. Surgeons must often make the decision as to the desirability and feasibility of separation. These decisions are complicated by ethical problems that involve patient privacy, the allocation of shared organs, and in some instances the necessity for one twin to die to save the other. Although life as a conjoined twin would appear to be intolerable, there are historical as well as current instances of conjoined twins who have progressed to adulthood as relatively well-adjusted individuals. Thus, in some situations, it may be better not to operate on these patients. At one time or another, when individual cases have been studied by theologians, all faiths have agreed that the sacrifice of one twin to save the other is ethical. When one twin is clearly stronger than the other and has the best chance for long-term survival, it also appears to be desirable to give that twin the shared organs that allow gastrointestinal and genitourinary function and ambulation. It is now possible to predict the pattern of shared organs in most cases based on an external examination. It is no longer necessary to subject these patients to prolonged, invasive tests, which may be dangerous and provide at best incomplete information. The surgeon should take great care to protect his patients' privacy and resist efforts by the media to create a "television circus"" over these patients.

The Royal Princess Anna Vasa. Historical note and radiological examination of her skeleton

Radiological findings on the skeleton of the Royal Princess Anna Vasa are presented. Anna Vasa (1568-1625) was the sister of Sigismund Vasa, who reigned as Sigismund III, king of Sweden and Poland. She was born in Sweden but spent most of her life in Poland. Her skeleton was removed from the tomb in Toruń during restoration work at St. Mary's Church in April 1994. It was then subjected to anthropological and radiological examinations (conventional radiography and CT). The studies revealed a number of anatomical deviations and pathological abnormalities; e.g. basilar impression and congenital anomalies of the spine. These findings can explain many of the complaints troubling Anna Vasa during her lifetime. A fragmentary historical outline and biography of Anna Vasa and Sigismund III are also presented.

Caroline Crachami, the Sicilian Fairy: a case of bird-headed dwarfism

One of the most remarkable cases of extreme dwarfism on record is Caroline Crachami, the Sicilian Fairy. She was born in 1815, and was taken to London to be exhibited for money in 1824. Due to her proportional dwarfism, severe intrauterine growth retardation, and typical "bird-headed" profile, Caroline Crachami has by some been diagnosed as a case of the autosomal recessive Seckel syndrome. In this historical vignette, the Sicilian Fairy's life and death are presented in some detail using new material, and the problem of her correct diagnosis is discussed.

Otto Ullrich and his syndromes

A half-century ago Otto Ullrich became the first clinical geneticist to assume the Chairmanship of a clinical department in a medical school. Clinical genetics owes Ullrich the delineation and definition of several important genetic diseases and syndromes, most importantly the condition named after him and Henry Turner. This paper reports on Ullrich's teacher, his career, his personality, and "his" syndromes.

History of the cerebrohepatorenal syndrome of Zellweger and other peroxisomal disorders

The history of the peroxisomal disorders (PDs), including the most frequent variant, the cerebrohepatorenal syndrome of Zellweger, can be divided into four phases. During the first phase, lasting from 1964 to 1972, the clinical and pathologic manifestations of Zellweger's syndrome (ZS) were explored and delineated. In 1973 it was found that ZS is due to the absence of peroxisomes in hepatocytes and renal tubular epithelial cells. With this discovery the second phase of ZS was initiated, which in subsequent years led to discovery of various defective peroxisomal functions. During the third phase, beginning in 1980, various other peroxisomal disorders were discovered, among them infantile Refsum's disease, hyperpipecolic acidemia, neonatal adrenoleukodystrophy, and rhizomelic chondrodysplasia punctata. During 1986 the etiology of the various PDs was identified by complementation studies, marking the beginning of the fourth phase of the history of the peroxisomopathies. It was found that ZS, neonatal adrenoleukodystrophy, and rhizomelic chondrodysplasia punctata represent different genetic entities, while Refsum's disease and hyperpipecolic acidemia are alleviated variants of ZS. Moreover, results of preliminary studies indicate that cells of one case of ZS may complement the cells of another ZS case, which could indicate genetic heterogeneity of ZS.

The Proteus syndrome: the Elephant Man diagnosed

Sir Frederick Treves first showed Joseph Merrick, the famous Elephant Man, to the Pathological Society of London in 1884. A diagnosis of neurofibromatosis was suggested in 1909 and was widely accepted. There is no evidence, however, of café au lait spots or histological proof of neurofibromas. It is also clear that Joseph Merrick's manifestations were much more bizarre than those commonly seen in neurofibromatosis. Evidence indicates that Merrick suffered from the Proteus syndrome and had the following features compatible with this diagnosis: macrocephaly; hyperostosis of the skull; hypertrophy of long bones; and thickened skin and subcutaneous tissues, particularly of the hands and feet, including plantar hyperplasia, lipomas, and other unspecified subcutaneous masses.

Historical note: the extraordinary handless and footless families of Brazil - 50 years of acheiropodia

The history of acheiropodia is divided into 4 phases: discovery, exploration, modern studies, and contemporary knowledge. The discovery phase (1929-1930) is represented by the publication of the 1st family. For about 30 years, it remained the only family referred to in a number of textbooks of medicine, biology, and others. In the exploration phase (1956-1966), the first family was reanalyzed, other families were ascertained and analysed, and some radiologic aspects of the anomaly were published. The modern phase (1968-1972) is characterized by a large series of studies on the clinical aspects of acheiropodia, including laboratory and radiological examinations, psychological tests, status of vision, electrocardiograms, etc. In the contemporary phase (since 1974), genetic aspects prevailed, and studies were published on segregation analysis, selection pressure, genetic load, mutation rate, etc. Each one of these 4 phases is analyzed in detail.

Loveable synophthalmus?

The ancient Greek gave cyclopia a place in the world literature. Recently, synophthalmia in a beautified form has appeared on the toy market. In both cases human phantasy has adapted the horrible congenital situations by doing the anatomically impossible changes of putting the nose in the right place and suggesting that these conditions could be compatible with life.