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Recent cases of conjoined twins Manar Maged, born 30 March 2004, Aghur, Egypt Manar Maged was born with a rare condition called craniopagus parasiticus, making her a a type of conjoined twin. Craniopagus refers to the twins being joined at the head (see Types of Conjoined Twins). Parasiticus describes the way that one twin is completely dependent upon the other. The condition occurs when an embryo begins to split into identical twins but fails to complete the process – as a result one of the conjoined twins is not properly developed. Twins born joined at the head are extremely rare, accounting for one in every 2.5 million births. Parasitic twins like Manar's case are even rarer. Manar's condition has only been recorded 10 times in medical history. The underdeveloped twin, attached to the upper left side of Manar's skull, has a brain but no body and depends entirely on Manar for survival. Despite having no lungs and being unable to breathe, her second head displays signs of independent consciousness. It blinks, tries to suckle and even smiles and cries. But the weight of the underdeveloped twin put a tremendous strain on Manar's heart, and would prevent her from crawling or sitting upright. Doctors felt that the only hope for Manar was separation from her twin. The 13-hour operation was carried out in the town of Benha, 25 miles north of Cairo, and was the first of its kind in the Middle East. Following surgery, Manar showed no signs of paralysis and could move her limbs. After the surgery, Manar's conjoined twin was buried; the family named her Islaam. Sadly, Manar died in March 2006 from a severe brain infection, 13 months after her operation. The case raises interesting questions about the nature of identity. At what point does the 'parasitic' twin in cases such as this develop an individual identity of its own? When it has a brain? A face? A beating heart? If it is capable of independent thought or movement? When should we stop viewing it as an additional part of one child's body and instead see it as another child, if a severely disabled one? See To Separate Or Not? for other challenging questions raised by cases of this kind. [top]
Laleh and Ladan Bijani, born 17 January 1974, Firouzabad, Iran Iranian sisters Ladan and Laleh Bijani had been conjoined at the head since birth. For as long as they could remember, they wanted to live as separate individuals. Both women studied law at Tehran University; Ladan wanted to be a lawyer, while Laleh had plans to become a journalist. The surgery to separate them took place at a hospital in Singapore in July 2003. It was the first time surgeons tried to separate adult siblings joined at the head. The major problem facing surgeons attempting this operation is to ensure that the blood supply to both brains is maintained at all times. Laleh and Ladan had been warned before the surgery that they had only a 50:50 chance of surviving the surgery, but both were determined to proceed despite the risks. As the operation progressed, it became clear that separation would be more complex than anticipated. After 29 years of sharing the same skull cavity, the twins' brains had fused together, and to separate them would involve cutting through their brain tissue millimetre by millimetre. The procedure was further complicated because the blood circulation between the twins was unstable. They were finally separated after 53 hours, but the twins suffered particularly heavy loss of blood, causing their circulatory systems to fail. Doctors tried to save the women by giving them emergency transfusions, but an hour after separation Ladan died. Her sister Laleh died 90 minutes later. The case prompted debate over the ethics of separation. Should the operation have gone ahead when the risks were so great, or should the wishes of the twins and quality of life issues take precedence? [top]
'Jodie' and 'Mary', born 2000, Manchester UK 'Jodie' and 'Mary' were the pseudonyms used for Gracie and Rosie Attard, whose parents came to the UK from the Maltese island of Gozo for their birth. The twins were joined at the lower abdomen and spine, but because they had only one functional heart and one set of lungs, separation meant the inevitable death of one twin. 'Mary'/Rosie was described as having 'primitive brain functions', while 'Jodie'/Gracie showed normal mental development. If left unseparated, both would have died. Their parents opposed separation because as Roman Catholics they believed that it was wrong to take human life. The case sparked an intense legal debate over:
The Court of Appeal ruled that the girls be separated and the operation took place when they were three months old. As expected, Rosie died. Gracie has made good progress, and should be able to lead a normal life. [top]
Esther and Stella Alphonce, born 1999, Tanzania The girls, joined at the spine, were born by Caesarean section. Their parents had no idea that they were expecting conjoined twins. The girls were treated at the Red Cross Children's Hospital in Cape Town, world experts in separation. Although Lucy, the mother, loved her twins just as they were, and was extremely afraid of the risks of separation, she agreed with the doctor's strong opinion that separation was essential because of the poor quality of life the girls could expect if left together. Separation involved parting the fused spinal cords, a procedure which had never been attempted before and which carried the risk that one or both might be left paralysed or incontinent. Both girls moved their legs within hours of the operation, indicating that the cords had been successfully divided. In June 2001, eleven months after their operation, they returned to their village in southern Tanzania, both healthy and happy, and learning to walk. [top]
Ja'Nishia and Ja'Lishia Lewis, born 1994, USA Before her twins were born, Josie Lewis was told that they had little chance of surviving beyond birth, because they shared an abnormal heart with only a single ventricle. When born, the girls were stronger than anticipated. Separation was mooted at birth and when the girls were five, but one twin would be sacrificed and there was no guarantee that the other would survive. Their mother refused to jeopardise either of the girls. Their frail heart eventually gave way under the strain of supporting two bodies, and they died aged six. [top]
Abigail and Brittany Hensel, born 1990, midwest USA A very rare, dicephalus pair, they have separate heads and necks, but share one torso and a pair of legs. Each has her own heart and stomach, and controls the limbs and feels sensation exclusively on her own side. They share three lungs and, below the waist, a single set of organs. Physically they move as one, in perfect co-ordination. Mentally they are independent, with different preferences and abilities. Their parents are opposed to separation, which would be highly dangerous. Even if successful, the girls would be left severely disabled, and unable to enjoy walking, running, swimming and bike riding which, together, they can do easily. [top]
Amy and Angela Lakeberg, born 1993, Chicago The girls were born with a joined heart and liver. Their heart was flawed, and the twins could not have survived together in the long term. Surgery involved sacrificing the weaker Amy in order to save Angela, whose chances of survival after surgery were also poor. The hospital where they were delivered advised against separation, but eventually the Children's Hospital in Philadelphia decided that there was an ethical obligation to attempt surgery in spite of the poor prognosis. Amy died during the operation and Angela lived only until 10 months, when she died of pneumonia. This case raised many issues about the separation of conjoined twins:
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Hassan and Hussein Abdulrehman, born 1986, Sudan The boys, extensively joined at the chest and pelvis, were successfully separated at eight months by Professor Lewis Spitz at Great Ormond Street Hospital in London. In infancy, Hassan was the weaker, and the boys' parents were told that he was unlikely to survive. Now teenagers, Hussein has the quieter personality, and Hassan is more outgoing. The boys had just two legs between them, and shared many organs. In surgery they were each given one leg, and skin from a useless third leg was used to cover their wounds. The boys are very close, but have no recollection of being joined. Despite undergoing numerous operations, and being left with some disabilities, they feel lucky and proud to have been separated. [top]
Elisa and Lisa Hansen, born 1978, USA These girls were the first pair joined at the brain to be successfully separated, in an operation performed in Salt Lake City by Drs Ted Roberts and Marion Walker. As infants, the girls co-ordinated their movements, with one crawling backwards as the other crawled forwards. Separation, at 19 months, took place in gradual stages, to allow their brains time to acclimatise. Lisa was left with significant brain damage and uses a wheelchair, while Elise is more able-bodied. Now adults, the twins lead happy lives with their family near Salt Lake City. [top]
Anna and Barbara Rozycki, born 1970, Coventry, UK Born joined at the breastbone and liver, the girls were immediately taken to Birmingham Children's Hospital where Dr Keith Roberts, now retired, separated them. Their birth was extremely traumatic for their mother, who endured 72 hours of labour and nearly died, and who never saw her daughters joined together. The twins are identical, and each has a scar from the separation, but neither has any physical disability. Both feel that they have a bond that is deeper than that between ordinary twins. 'Even as toddlers we had a special bond,' says Anna. 'If one of us gets ill, so does the other one. If one is upset, the other feels it. We are definitely two parts of the same whole.' [top]
Lori and Reba Schappell, born 1961, Pennsylvania The only pair of unseparated adult twins alive today with a join at the top of the head. They have separate brains and thought processes, but share some tissue and blood supply, making separation impossible. Reba is much shorter than Lori, and sits on a wheeled stool, which Lori navigates. Institutionalised as children, they have fought against the label of 'mental handicap' and now live successfully in the outside world, without help. Their personalities and interests are very different, but the twins love each other and say they don't want to be separated. They object to the assumption that such close proximity makes their life unbearable. 'Assume it's not difficult,' says Lori, 'until we tell you it is'. [top]
Masha and Dasha Krivoshlyapova, born 1950, Moscow The twins have two heads and trunks, four arms, and three legs. At birth they were taken away from their mother, and she was told that they had died. The third leg, emerging from their back, was amputated when they were about 10 years old. For their first 40 years they were incarcerated in degrading Soviet institutions. Archive film of them as babies shows their responses being cruelly tested with razors and pins. Until the age of six they were kept in a cot, hardly able to talk, use the toilet or feed themselves. They now live just outside Moscow in a home for war veterans, but are derided by the Russian press and people, who give them no sympathy or understanding. Only a handful of people care about them. Dasha finds the abuses they suffer particularly hard to tolerate. She suffers from depression and alcoholism, and Masha has now become alcoholic too.
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