Conjoined twins, born with their bodies physically linked, have intrigued people for centuries. Although the few pairs who have survived unseparated into adulthood can describe their experience, it's impossible to imagine what it is like to have such an intimately shared existence, joined to another human being 24 hours a day.
As surgical techniques improve, more of these rare children can be separated, although the operation always carries risks, and sometimes means the death of one or even both. Deciding to separate means making ethical and moral judgements that question many of society's basic assumptions about individuality, the need for privacy, and whether we have the right to rob one individual of life in order that another, stronger, person may live.
Whatever their situation, conjoined twins are extraordinary and memorable, and we can only marvel at the co-operation and compromise that underpins their daily lives. In Joined we see them, not as freaks, but as real, unforgettable people, caught up in a rare and remarkable physical phenomenon that the rest of us can barely imagine.
The history of conjoined twins
Conjoined twins have fascinated people throughout history, and their images are found in cave drawings and carvings dating back many centuries. In earliest times they were worshipped as gods, or feared as bad omens and exiled, abandoned or killed. Later they were viewed as curiosities, and of the few sets who survived into adulthood, many became circus or sideshow attractions, or went on to the stage. Only in the last 30 years, as separation techniques have become increasingly sophisticated, have conjoined twins begun to be seen as individuals rather than freaks.
HISTORICAL; The Biddenden Maids, 1100-1134
Eliza and Mary Chulkhurst lived in Kent, in the UK, and were joined at hip and shoulder. When one twin died, the remaining one is alleged to have refused separation, saying, 'As we came together, we will also go together'. She died shortly after her sister. The twins left 20 acres of land to the poor, and every Easter commemorative cakes, decorated with their image, are given to visitors to the village.
Lazarus and Joannes Baptista Colloredo, 1617-1640s or '50s
An example of parasitic twins, a rare type of conjoined twin where one of the pair does not form fully, and remains physically dependent on the other. The shrunken form of Joannes Baptista, whose body had begun to atrophy in the womb, appeared to grow out of Lazarus's torso. Born in Italy, they toured Europe and lived into their thirties.
Chang and Eng Bunker, 1811-1874
The original 'Siamese twins', they were born to a farming family in Siam (now Thailand). A 12cm ligament joined them near the breastbone. Nowadays separation would be straightforward, but although the twins asked surgeons to try, no-one was willing to attempt the operation. The King, Rama II, said they should be put to death in infancy, but their mother protected them until 1829, when they went to America. Their years spent touring the world as curiosities earned them enough to set up a farm in North Carolina, where they married the Yates sisters and between them fathered 21 children. When Chang died of pneumonia in 1874, aged 63, Eng refused separation and died a few hours later.
Millie and Christine McKoy, 1851-1912
Known as the Two-Headed Nightingale, the girls were black slaves born in North Carolina. They were separated from their family in infancy and sold for $30,000, but were reunited with their mother at the age of four. Joined back-to-back, they became vaudeville stars and toured the world, singing, dancing and playing the piano. Millie died of tuberculosis in 1912, aged 61, and Christine's death followed less than a day later.
Giovanni and Giacomo Tocci, 1877-1940s
A very rare type of twin, the Tocci brothers had two heads, and two pairs of arms, but shared a lower body from beneath their sixth rib. Their shared legs were very weak, with one deformed foot, so the boys found it hard to stand, and could not walk. Born in Italy, they lived into their sixties, but refused to be exhibited once they were out of their teens.
Simplico and Lucio Godina, 1908-1936
Male twins from the Philippines, they were joined at the back and made a living as entertainers, dancing and roller skating. They married twin sisters, and the four performed together on stage. When Lucio died of pneumonia, Simplico was successfully separated, only to die shortly afterwards from an infection.
historical separations ;
Surgeons have always been fascinated by the challenge of separating conjoined twins, and there have been many remarkable operations over the centuries. Until the mid-20th century, separation was attempted only if:
The join was simple, unlikely to involve shared liver or other organs, and situated away from the head, heart or pelvis.
The children had already survived beyond the first few months.
Earliest separation
The first successful separation was in Basle, in 1689, of twins joined by a ligament just 2.5cm long and 12cm wide. Both survived.
19th-century surgery
In 1860, girls joined at the torso were separated by their father, a physician. Only one survived.
Paediatric advances in the last century
As paediatrics developed, so surgeons grew more daring. In 1955, Dr Rowena Spencer separated the newborn Duckworth twins 18 hours after birth, in order to save the life of the stronger twin. The girls had two upper bodies, but only one lower body, inside which were two kidneys, two bladders, two uteruses, and two or three vaginas. The survivor, Linda Duckworth, is still alive, and lives in Mississippi.
The liver was considered a risky prospect for separation, because of the danger of haemorrhage. In 1970, Mr Keith Roberts, a Birmingham surgeon, successfully separated Anna and Barbara Rozycki, joined at breastbone and liver. Both are still alive, Anna living with her parents, Barbara married with children.
21st-century practice
Separation nowadays is attempted far more frequently, but this in itself raises many medical, ethical, cultural and religious questions, as parents struggle to make the right choice for the long-term wellbeing of their children.
Conjoined Twins
Facts About Conjoined Twins
Births of conjoined twins, whose skin and internal organs are fused together, are rare. Conjoined twins occur once every 200,000 live births, and their survival is anything but assured.
Approximately 40 to 60 percent of conjoined twins arrive stillborn, and about 35 percent survive only one day. The overall survival rate of conjoined twins is somewhere between 5 percent and 25 percent.
For some reason, female siblings seem to have a better shot at survival than their male counterparts. Although more male twins conjoin in the womb than female twins, females are three times as likely as males to be born alive. Approximately 70 percent of all conjoined twins are girls.
How They Are Formed
Conjoined twins are genetically identical, and are, therefore, always the same sex. They develop from the same fertilized egg, and they share the same amniotic cavity and placenta.
Twinning occurs one of two ways: either a woman releases two eggs instead of the usual one or she produces only one egg that divides after fertilization. If she releases two eggs, which are fertilized by separate sperm, she has fraternal twins. When a single, fertilized egg divides and separates, she has identical or paternal twins.
In the case of conjoined twins, a woman only produces a single egg, which does not fully separate after fertilization. The developing embryo starts to split into identical twins during the first few weeks after conception, but stops before the process is complete. The partially separated egg develops into a conjoined fetus.
A History of Conjoined Twins
One of the earliest documented cases of conjoined twins were Mary and Eliza Chulkhurst. They were born in Biddenden, County of Kent, England in the year 1100, and were joined at the hip.
The wealthy sisters, who were known as the Biddenden Maids, lived for 34 years. When they died, they left a small fortune to the Church of England. In honor of their generosity, it was customary for English citizens to bake little biscuits and cakes in the sisters' images and give them to the poor.
Another set of famous conjoined twins was Eng and Chang Bunker, who were born in Thailand (then called Siam) in 1811. The term Siamese twins was coined as a reference to Eng and Chang, who achieved international fame shortly after leaving Siam as teenagers.
They were joined at the lower chest by a narrow band of flesh, which connected their livers. They were exhibited in circus shows around the world before settling in the United States, where they married two sisters and had nearly two dozen children. They were successful businessman and ranchers in Wilkes County, North Carolina, where they lived until 1874. They were 63 years old when they died.
The term Siamese twins is no longer considered appropriate. Conjoined twins aren't limited to any racial or ethnic group and indeed have been born all over the world.
Various Types of Conjoined Twins
There are nearly a dozen different types of conjoined twins. One of the most common classifications is thoracopagus twins. These twins are connected at the upper portion of the torso.
Thoracopagus twins share a heart, which, depending on how closely they are joined, makes it nearly impossible to separate them and save them both. Thoracopagus twins make up about 40 percent of all conjoined cases.
Another common type of conjunction is called omphalagus, where twins are connected from the breastbone to the waist. About 33 percent of all conjoined cases are categorized as omphalagus. These twins may share a liver, gastrointestinal or genitourinary functions, but rarely share a heart.
One of the rarest types of conjoined twins is craniophagus twins, which are joined at the cranium or head. In fact, only 2 percent of all conjoined twins are joined in this way.
Separating Twins: No Easy Matter
The surgical separation of conjoined twins is a delicate and risky procedure, requiring extreme precision and care. Therefore, the decision to separate twins is a serious one.
Mortality rates for twins who undergo separation vary, depending on their type of connection, and the organs they share. For example, twins joined at the sacrum at the base of the spine have a 68 percent chance of successful separation, whereas, in cases of twins with conjoined hearts at the ventricular (pumping chamber) level, there are no known survivors.
Although success rates have improved over the years, surgical separation is still rare. Since 1950, at least one twin has survived separation about 75 percent of the time.
It is only after twins are born that doctors can use magnetic resonance imaging, ultrasound and angiography to find out what organs the twins share. In order to determine the feasibility of separation, doctors must carefully assess how the twins' shared organs function.
After separation, most twins need intensive rehabilitation because of the malformation and position of their spines. The muscles in their backs are constantly being flexed and they often have a difficult time bending their backs forward and backwards and sitting up straight.
The facts on conjoined twinsAn average of one set of Siamese, or conjoined, twins is born in the UK each year. Conjoined twins are created when a fertilised egg attempts to divide into identical twins, but fails to split completely.
The fastest-ever operation to separate conjoined twins lasted 45 minutes. The operation took place earlier this year at Great Ormond Street Hospital when Professor Lewis Spitz and fellow surgeon Edward Kiely operated on twin babies Zainab and Jannat Rahman, who were joined from the middle of the chest to the abdomen, and shared a liver.
Other conjoined twins who have survived the operation to separate them include Eman and Sanchia Mowatt, who were joined at the spine. They were separated in September 2001 during a 16-hour operation in Birmingham, even though there was a risk of paralysis because they had fused spinal cords.
Not every case ends so successfully. In 2000, Rosie Attard died after surgeons in Manchester separated her from her sister Gracie to save Gracie's life. Their Maltese parents, Michael and Rina, who felt that their daughters' fate should be left in the hands of God, fought a court battle to prevent the operation from going ahead, but lost the case. Two years on, they believe that it was God's plan to allow the operation to go ahead to save Gracie.
Sharing a heart, Natasha and Courtney Smith from St Albans, Herts, would not have survived surgery, according to doctors and both, sadly, died last May.
The world's oldest Siamese twins, Masha and Dasha Krivoshlappova, died earlier this year at the age of 53. They were taken into state care in Russia as babies and subjected to gruelling experiments but managed to survive the ordeal. Their adulthood in Moscow was also unhappy. Dasha started drinking heavily, which left her sister also feeling the effects of vodka because of their shared circulatory system.
Hussein and Hassan Salih, born in Sudan, who were fused together from the chest to the hip and shared a liver, were successfully separated. Now, 16 years on, they are strong and energetic, and have just taken their GCSEs in west LondoN
What is it about the idea of conjoined twins that so fascinates people? What is it about the idea of conjoined twins that so fascinates people? The original Siamese twins, Chang and Eng, who shared a liver, made a living in Victorian times by parading themselves for the public in America and Britain. Although they had enough money to retire to the greater dignity of a farm in North Carolina, they remained a curiosity, and a metaphor for the United States - E pluribus unum, one and united.
The life and death drama of Natasha and Courtney Smith, from St Albans, Hertfordshire, has been paraded in the papers in intimate detail since February, after their dad and 24-week pregnant mum sold exclusive rights to their story to the Sun.
Yes - to leap in ahead of any accusations of hypocrisy - the Guardian ran stories about them too. So we did last year about the Maltese twins, when their Catholic parents opposed the separation and a court ruled against them. Originally it seemed as though the case of Natasha and Courtney might raise similar issues. But in fact the two stories could hardly be more different.
In the Maltese case, the parents arrived in the UK for the birth. They did not want them separated because it would mean seeking the death of one to save the other. Their supporters included pro-life groups and medical ethicists who felt parental rights were being overridden.
It must have been the hardest few months of the parents' lives. They behaved with great dignity. The court ruled against them, and at the eleventh hour, rather than appeal, they agreed that the operation should go ahead. Although newspapers wrote screeds about the ethics of the decision and the complexity of the operation, the family enjoyed as much privacy as possible in the circumstances. Nobody knew their identity or was allowed to intrude into their feelings.
Rina and Michael Attard did eventually go public. In June last year, when the worst was over and Jodie was recovering in a Manchester hospital, they agreed to exclusive interviews and pictures of the baby with the Mail on Sunday, the News of the World and Granada TV, in return for a six-figure sum. The money went into a trust fund for the surviving twin - revealed as Gracie - who would need further expensive medical treatment.
And then we have Natasha and Courtney Smith. In November last year, just five months after the Attards sold their story, Tina May and her partner Dennis Smith were told after a routine scan at 14 weeks that the twins she was carrying had one heart between them.
Doctors at Queen Charlotte's hospital, which then took over management of the pregnancy, insist they kept the parents fully informed throughout. At 20 weeks, shortly before the deal with the Sun, Lewis Spitz, the world expert in separating conjoined twins, became involved. Dr Spitz, based at Great Ormond Street, knows better than anyone that no twin born sharing a heart has survived separation. Indeed, in 1986, 1989 and in 1994, he had made the tough decision not even to try to operate on twins who shared a heart - and they had died.
Ms May and Mr Smith, who refused a termination, would have been told more than once that it would take a medical miracle to keep either twin alive. At 30 weeks, it was clear the heart was seriously abnormal, with not only a large hole but crossed arteries. Tests soon after the birth confirmed the doctors' fears. The parents would have been told there was no hope unless the twins survived a month - regarded as highly unlikely.
It is almost too agonising to contemplate, and yet the parents have lived through the last months in the full-on glare of the Sun. In February, it ran pages of exclusive, in-depth probing of their distressing circumstances. There was more of the same shortly before the birth. Then there was the birth itself. Each time it was packaged as another Attard dilemma - that Courtney must die to save Natasha. Only once did the Sun nod towards the greater truth, which was that it was possible both babies would die.
Maybe Ms May and Mr Smith have sufficient inner strength to deal with the enormity of their tragedy and that sort of newspaper exposure at the same time. But you cannot help wondering whether they felt able to discuss and grieve freely over their predicament with the Sun at their elbow. Was it worth the money?
Great Ormond Street hospital sought and won a court injunction to keep the press out the moment the babies were turned over to them. The hospital said it wanted to protect the staff and the babies. Perhaps it was just as much to protect the parents
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