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For other uses, see. Conjoined twins are joined. An extremely rare phenomenon, the occurrence is estimated to range from 1 in 49,000 births to 1 in 189,000 births, with a somewhat higher incidence in Southeast Asia and Africa. Approximately half are , and an additional one-third die within 24 hours. Most live births are female, with a ratio of 3:1. Conjoined twins Synonyms Siamese twins X-ray of conjoined twins, cephalothoracopagus. Two contradicting theories exist to explain the origins of conjoined twins. The more generally accepted theory is fission, in which the fertilized egg splits partially. The other theory, no longer believed to be the basis of conjoined twinning, is fusion, in which a fertilized egg completely separates, but which search for similar cells find similar stem cells on the other twin and fuse the twins together. Conjoined twins share a single common , , and , although these characteristics are not exclusive to conjoined twins, as there are some monozygotic but non-conjoined twins who also share these structures in utero. The most famous pair of conjoined twins was Thai: อิน-จัน, In-Chan 1811—1874 , brothers born in Siam, now. They traveled with 's circus for many years and were labeled as the Siamese twins. Chang and Eng were joined at the torso by a band of flesh, cartilage, and their fused livers. In modern times, they could have been easily separated. Conjoined twins are typically classified by the point at which their bodies are joined. These twins usually share a heart, and may also share the or part of the. The is always involved in these cases. As of 2015, separation of a genuinely shared heart has not offered survival to two twins; a designated twin may survive if allotted the heart, sacrificing the other twin. Unlike thoracopagus, the heart is never involved in these cases; however, the twins often share a , , and other organs. These twins can be conjoined at the back of the head, the front of the head, or the side of the head, but not on the face or the base of the skull. These twins generally cannot survive due to severe malformations of the brain. Also known as janiceps after the two-faced Roman deity or syncephalus. In this type of twins, there are two faces facing in opposite directions, or sometimes a single face and an enlarged skull. These twins almost never share any vital organs, with the exception of the liver. A famous example is. These twins have four arms; one, two, three or four legs; and typically one external set of and. These twins have four arms, and two, three, or four legs. Twins that are dithoracic parapagus are fused at the abdomen and pelvis, but not the thorax. Twins that are have one trunk and two faces. Twins that are have one trunk and two heads, and have two dibrachius , three tribrachius , or four tetrabrachius arms. The first is that a single fertilized egg does not fully split during the process of forming identical twins. The second theory is that a fusion of two fertilized eggs occurs earlier in development. Although conjoined twinning has not been linked to any environmental or genetic cause, they occur so rarely it has not been possible to draw firm conclusions. Separation Surgery to separate conjoined twins may range from very easy to very difficult depending on the point of attachment and the internal parts that are shared. Most cases of separation are extremely risky and life-threatening. In many cases, the surgery results in the death of one or both of the twins, particularly if they are joined at the head or share a vital organ. This makes the of surgical separation, where the twins can survive if not separated, contentious. The first record of separating conjoined twins took place in the in the 900s when the surgeons tried to separate a dead body of a pair of conjoined twins. The result was partly successful as the other twin managed to live for three days. The next case of separating conjoined twins was recorded in 1689 in Germany several centuries later. The first recorded successful separation of conjoined twins was performed in 1689 by Johannes Fatio. In 1955, neurosurgeon Harold Voris 1902-1980 and his team at in Chicago performed the first successful operation to separate conjoined at the head , which resulted in long-term survival for both. The larger girl was reported in 1963 as developing normally, but the smaller was permanently impaired. In 1957, Bertram Katz and his surgical team made international medical history performing the world's first successful separation of conjoined twins sharing a vital organ. Omphalopagus twins John Nelson and James Edward Freeman Johnny and Jimmy were born in Youngstown, Ohio, on April 27, 1956. The boys shared a liver but had separate hearts and were successfully separated at North Side Hospital in Youngstown, Ohio, by Bertram Katz. The operation was funded by the Ohio Crippled Children's Service Society. Recent successful separations of conjoined twins include that of the separation of in 2001, who were born in , in 2000. The 197-hour surgery on the pair of was a landmark one which took place in ; the team was led by neurosurgeons Chumpon Chan and Keith Goh. The surgery left Ganga with brain damage and Jamuna unable to walk. Seven years later, Ganga Shrestha died at the Model Hospital in Kathmandu in July 2009, at the age of 8, three days after being admitted for treatment of a severe chest infection. The twins were attached at the lower abdomen and spine. The surgery took place in November, 2000, at in. The operation was controversial because Rose, the weaker twin, would die as a result of the procedure as her heart and lungs were dependent upon Grace's. However, if the operation had not taken place, it was certain that both twins would die. Grace survived to enjoy a normal childhood. In 2003, two 29-year-old women from Iran, , who were joined at the head but had separate brains craniopagus were surgically separated in Singapore, despite surgeons' warnings that the operation could be fatal to one or both. Their complex case was accepted only because technologically advanced graphical imagery and modelling would allow the medical team to plan the risky surgery. Unfortunately, an undetected major vein hidden from the scans was discovered during the operation. The separation was completed but both women died while still in surgery. Moche ceramics depicting conjoined twins. The culture of ancient depicted conjoined twins in their ceramics dating back to 300 CE. Legend says that their father, , separated his conjoined sons with a sword and that some priests believed that the blood that had flowed between them signified wars between their progeny confrontations did occur between Banu al'Abbas and Banu Ummaya ibn 'Abd Shams in the year 750 AH. The described conjoined twins in his book Kitab-al-Saidana. The English twin sisters , who were conjoined at the back pygopagus , lived from 1100 to 1134 or 1500 to 1534 and were perhaps the best-known early historical example of conjoined twins. Rita and Cristina were dicephalus tetrabrachius one body with four arms twins and although they died at only eight months of age, they gained much attention as a curiosity when their parents exhibited them in Paris. Grave of Eng and Chang Bunker near Several sets of conjoined twins lived during the nineteenth century and made careers for themselves in the , though none achieved quite the same level of fame and fortune as Chang and Eng. Most notably, or McKoy , pygopagus twins, were born into slavery in North Carolina in 1851. They were sold to a , J. Smith, at birth, but were soon by a rival showman. The kidnapper fled to England but was thwarted because England had already banned slavery. Smith traveled to England to collect the girls and brought with him their mother, Monimia, from whom they had been separated. He and his wife provided the twins with an education and taught them to speak five languages, play music, and sing. In 1912, they died of , 17 hours apart. The Toccis, born in 1877, were dicephalus tetrabrachius twins, having one body with two legs, two heads, and four arms. From birth they were forced by their parents to perform and never learned to walk, as each twin controlled one leg in modern times, allows twins like the Toccis to learn to walk on their own. They are said to have disliked show business. In 1886, after touring the United States, the twins returned to Europe with their family, where they fell ill. They are believed to have died around this time, though some sources claim they survived until 1940, living in seclusion in Italy. They are the earliest set of conjoined twins whose names are purportedly known. Viet died on October 6, 2007. Both graduated in 2012 from , St. Paul, hired as teachers. They later moved to the United States for healthcare with their parents. They were successfully separated in August 4, 2004. The girls shared some major veins, but their brains were separate. They were separated on September 16, 2004, although Tabea died about 90 minutes later. As , the top of Tatiana's head is attached to the back of Anastasias's head. She had four arms and four legs, resulting from a joining at the pelvis with a headless undeveloped parasitic twin. Born October 25, 2006. Share part of their brain and can pass sensory information and thoughts between each other. They are craniopagus twins, joined on the tops of their skulls and sharing a small amount of brain tissue. In 2009, they were separated in ,. Conjoined by the liver, pancreas, and a small portion of their small intestine. Separation occurred on November 7, 2011. Conjoined by their sternum, pericardium, and liver. In 2014, they were separated in Shanghai, China, at the Shanghai Children's Medical Center. The story follows the life and survival of conjoined twin sisters. The book also won 's 2016 prize for young adult fiction and the. They were separated at birth by , and Hugo was imprisoned in the Simpsons' attic. The episode also includes a reference to Chang and Eng. They both serve as antagonists. They were surgically sewn together, much like an experiment performed by Josef Mengele, also known as the Angel of Death, in which a pair of twins were sewn together back to back by blood vessels and organs, in an attempt to create conjoined twins. This performance is done with the help of CGI. They later split during an , and reunite for the rest of the show. They are dicephalic parapagus twins where they have four arms and share the same tentacles that are in place of their legs. University of Maryland Medical Center. Retrieved 6 Jan 2012. Retrieved 22 Oct 2015. First Aid for the USMLE Step 1: 2010 20th Anniversary Edition. University of Maryland Medical Center. Retrieved February 9, 2010. Archived from on 2010-08-15. Kompanje 1 December 2004. Twin Research and Human Genetics. The University of Chicago Photographic Archive. Retrieved October 14, 2015. Retrieved October 14, 2015. Retrieved October 14, 2015. Retrieved April 11, 2013. Channel News Asia Singapore. Archived from on January 14, 2011. Retrieved March 27, 2010. Retrieved March 27, 2010. The Spirit of Ancient Peru:Treasures from the. New York: , 1997. Separation of craniopagus conjoined twins: an evolution in thought.