What happens when one conjoined twin dies?

In about May 1811 a rare phenomenon occurred with the birth of Chang and Eng Bunker in Rattanakosin Kingdom or Siam (today’s Thailand). What made these twin brothers famous was the fact that they were conjoined at the sternum. They were widely exhibited, and were the era’s most studied humans. As a result, the term ‘Siamese Twins’ became synonymous with conjoined twins.

This extraordinary anomaly of twins joined in utero happens only in about one in 70,000 births more commonly in Southwest Asia and Africa. Most are female (about 70%), many are stillborn and some die within a day. The reasons why and how conjoined twins are formed are still a mystery – the most adequate explanation is that fission – a partial split of the fertilized egg – occurs.

Questions abound regarding how this occurs, why do some survive, how do these twins have sexual relationships (if possible) and what happens when one of them dies. Let’s examine some of the most well-known cases.

It’s hard to imagine a life as a conjoined twin where everything is shared with another.

Chang and Eng Bunker

were born in a village called Meklong. Their mother, Nok was probably Siamese/Chinese, mixed with Malay. She apparently claimed the twins’ birth wasn’t more challenging than any of her other children’s. Their father, Ti-eye, a fisherman with Chinese roots, died when a smallpox epidemic ravaged their area in 1819. Nok raised ducks with the help of her kids and treated Chang and Eng just like her other children, not paying any special attention to their strange condition. The twins played with other kids just like normal children do.

In 1824 a Scottish merchant, Robert Hunter, was in a fishing boat on the Menam River at dusk and  thought he saw a ‘strange animal’ swimming. When he realised that he’d discovered the twins, he saw a way to rake in the cash. After five years of petitioning the king of Siam, who forbade him to take the twins out the country and had ordered their death, he finally took them off to the US. He and the American sea captain, Abel Coffin signed a contract with the 18-year-old twins for a tour, which lasted five years. Abel Coffin remained a father figure to the twins for years. Later, the brothers were distressed to hear a rumor that their mother had sold them into slavery.

The Siamese twins set out on their travels

Chang and Eng landed in Boston on 16th August 1829. They were checked out by physicians, and became a media sensation and popular exhibit. They then toured the British Isles and returned to New York in March 1831. By that time they were skilled in English, and sought to appeal to a more upper-class sector, although their exhibitions could appear crude. They went to Europe again, then back to the US. James W. Hale became their first manager.

In 1831 the twins were jeered at and harassed in Lynnfield, Massachusetts and struck a man. He reacted by hitting one of their heads with a stone, causing bleeding. The twins fired blanks at him which led to their arrest. Their angry manger resigned and was replaced by Charles Harris.

Chang and Eng faced several other conflicts and audience upheavals. They felt abused by Mrs Coffin, and escaped to Bath, New York where Abel found them and gave them a good thrashing for ‘whoring, gaming and drinking’. Thereafter the twins obtained their freedom, and continued to perform on their own.

Favourite fact:
Chang and Eng Bunker (the famous conjoined twins that popularised the term "Siamese twins") had separate wives (Sarah Yates and Adelaide Yates) who were, themselves, sisters! Between them, they had 20 children. pic.twitter.com/dc7DIBFXmr

— Srikanth Rajkumar (@SonOfRajkumar) April 23, 2023

In 1839, they purchased land and settled in Wiles County, Northwest Carolina, stopped performing and turned their focus to business trading. Disregarding public objections and condemnations, the twins married – Eng to Sarah Yates and Chang to Adelaide Yates. They took on the surname of Bunker, because of a woman they’d admired.

The twins bought another property in Mount Airy, and lived a luxurious life as plantation owners with several slaves. Adelaide birthed four children and Sarah three. Chang and Eng began performing and touring again in 1849 to earn more money for their now expanded families. Their performances became more distinguished and intellectual. They returned home in April 1861 at the outbreak of the American Civil War; by 1865 when the war ended, they had suffered financial losses and their slaves were emancipated, so they once again went on tour.

In 1860 they signed up with the famous P.T. Barnum for a month, but they didn’t get on with him so they declined his offer of a longer tour. Between 1868 and 1870 they traveled to Britain, Germany and Russia – their plans to further tour Europe were thwarted by the Franco-Prussian War. During their voyage home, Chang suffered a stroke and his right side, which faced Eng, became paralyzed, so they finally retired.

Chang became a heavy drinker and his health deteriorated. Reports state that he had suffered a bout of bronchitis, and early in the morning of 17th January 1874, his nephew checked in whilst the twins were asleep, and informed Eng that Chang was dead. Eng declared, ‘Then I am going’ and passed away a mere two hours later. The twins were 62 at the time, and until 2012 held the record for being the longest-living conjoined twins.

Chang’s death was possibly attributed to a cerebral blood clot, but the cause of Eng’s death was never established. The most popular theory was that he had died of shock, or that his body could not circulate blood back from his brother’s deceased body.

Because Chang and Eng were connected at the sternum and their livers were connected, it was presumed that undergoing surgery for separation would have been fatal. Indications are that had they had the medical technology now available, they could have been separated successfully.

Chang and Eng left a legacy behind them. They were mentioned and immortalised in films, plays, poetry, novels, pamphlets, cartoons and the musical, “Chang & Eng” by Ekachai Uekrongtham, which premiered in Singapore in 1997. They also featured in the 2017 musical “The Greatest Showman”, about the Barnum & Bailey Circus.

Chang and Eng are commemorated by a statue in their birth town (now known as Samut Somgkhram). Their fused livers were preserved in a jar with their death cast and are displayed in the Mütter Museum in Philadelphia; there’s also an exhibit at the Andy Griffith Museum, as well as the Circus World Museum.

The lives and deaths of some well-known conjoined twins

Ronnie and Donnie Galyon – born in Dayton, Ohio on 28th October 1951 – feature in the “Guinness Book of World Records” for being the longest-surviving conjoined twins. Joined from sternum to groin, they shared their lower pelvic organs and lived their lives face-to-face. After being studied for over two years in the St. Elizabeth Hospital, it was speculated that they wouldn’t survive very long, but it was decided that it was unsafe to separate them. They were never formally educated because they were thought to be a distraction at school, and so remained illiterate. Their father, Wesley, who had nine kids to support, took the twins on tour as a sideshow attraction around the US and then later Latin America and Canada.

Ronnie and Donnie became celebrities, and earned enough to support their family and to retire in 1991. They bought their first home, and appeared on television numerous times e.g. “The Jerry Springer Show” in 1997, on Discovery Channel in 1998, on Channel Five in 2009 and in numerous YouTube videos.

Even though it was difficult for them to get around, simple tasks were always a challenge and it took them a while to learn how to keep house – they were pretty much independent. They were American football fans, and got to realise their dream when they saw their favourite team, the Dallas Cowboys in the NFL. It was a logistical ordeal to fly them there with the custom-made wheelchair their youngest brother, Jim had arranged for them.

According to Jim and his wife Mary, who were always there to support and help the young men, they would have loved to have gone to school and to have had a normal life and relationships, but it simply wasn’t possible.

Ronnie contracted a lung infection, and they both passed away on 4th July 2020. Their doctor, Dr. Glenn Kwiat, described how commonly when one twin dies the other might not die right away and can live for up to another day. As it’s a deeply distressing situation, the surviving twin is usually sedated until nature takes its course.

Lori and Dori (George) Schappell

were born in Pennsylvania on 18th September 1961. They were joined by the head (craniopagus), facing in opposite directions and had partially fused skulls. They shared 30% of their brains and blood vessels, an extremely rare (2 – 6%) of documented cases.

Sadly, their parents were shocked and confused by the birth of their strange babies, and placed them in an institution for mentally handicapped people where they spent the first 24 years of their lives. Thanks to a good samaritan, Ginny Thornburgh, the wife of the former governor of Pennsylvania, who proved that they were not intellectually disabled, the twins were able to leave the institution, and moved into their own apartment in a high-rise building in Reading, Pennsylvania.

Lori and Dori featured on television in many talk shows and documentaries, as well as acting as fictional conjoined characters Rose and Raven Rosenberg in an episode of “Nip/Tuck” in 2004.

In 2007 Lori came out as transgender and became ‘George’, which made them the first set of conjoined twins identifying themselves with different genders. Lori was able to walk, while her brother had spinal bifida and couldn’t walk unaided, so she pushed him around on a mobile high stool. Lori worked in a hospital after obtaining a college degree, and while she was working, George would sit reading a book. George was a professional country singer, and even worked overseas. Their lives were completely made up of sacrifice and patience, and Lori was quoted by the LA Times as saying, ‘It all comes down to compromise. If more people in life did that, the world would be a better place.’

The twins were 62 years old when they passed away on 7th April 2024. The cause of death has never been publicly revealed.

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Types of conjoined twins

There are many types of conjoined twins, but the most common is thoracopagus, meaning connected in the upper ribcage. In this case if they share a heart, when one dies the living twin would more than likely suffer septic shock and organ failure.

Omphalopagus is twins conjoined from the breastbone to the waist, whereby they might share organs such as the liver and a gastrointestinal and reproductive system. An operation to separate them would depend on where they are attached, but ais generally highly risky. Many separations in the past have resulted in death for one of the twins.

History of conjoined twins partly successful separations

Ancient artworks and literature have depicted conjoined twins from as early as 300 in Peru, Palestine, Arabia, England, Scotland, Hungary, Italy etc. There is an historical record of a separation during the 900s where doctors tried to separate a twin that had died from its living twin. The survivor lived for three days after surgery.

In 1689 in Germany, Dr. Johannes Fatio performed the first known successful split. Also Dr Böhm operated on his own omphalopagus children, four days after which the weaker one died. In 1955 the first successful operation to separate craniopagus twins was undertaken in Chicago, and both survived for many years although one suffered permanent brain damage.

Faith and Rose were born in February 1999. Their mother learnt during her 14th week of pregnancy that she was carrying conjoined babies and was advised to have an abortion, but she opted to give birth anyway.

The babies were joined hugging face-to-face. Rose was parasitic and depended on Faith’s heart for her blood circulation. They were separated when three days old, as keeping Rose alive would have also killed her sister. Rose died 24 hours after surgery and Faith lived on – Faith took on ‘Rose’ as her second name. She endured multiple surgeries and adjustments, not to mention the trauma of being labeled a ‘freak of nature’ at school, but her greatest desire was to be an inspiration to others. She’s currently writing a children’s book about undergoing several operations, to settle other kids’ minds. She married on 16 October 2021 at the age of 22 to Tyler Roberts, a US Marine.

Some fully successful separations

In 1957, history was made by the first successful separation of omphalopagus twins James Edward (Jimmy) and John Nelson (Johnny) Freeman, born in Youngstown, Ohio on 27 April 1956. Both survived.

A great success story is that of Lillian and Linda Matthews-Wilson, who were separated in 1955 and survived. When their mother went into labour, she had no idea that she was carrying twins until the doctor realized there was something strange going on. Lillian and Linda were safely delivered connected from the navel to the sternum and sharing a liver. Their separation surgery took place when they were about five weeks old, and against all odds the two survived. They turned 68 years old in 2024, have seven children and are grandmothers to 16 children between them.

Similarly, AmieLynn and JamieLynn Arciniega were born in October 2022, conjoined in the same way including sharing a liver. Their parents were shocked to find out that they were conjoined through an ultrasound taken in the 10th week of pregnancy. They chose to continue, and in January 2023, 25 doctors at Cook Children’s Medical Center, Fort Worth, Texas successfully separated the twins after an 11-hour surgery. Their future looks bright, and doctors are optimistic about their recovery and ability to live normal lives.

The most recent success story of a separation

In a 14-hour operation,  London surgeon Professor Noor ul Owase Jeelani with a team of doctors operated on twin girls Minal and Mirha on 19th July 2024, in Gemini Untwined in Turkey; the craniopagus baby girls were born in Pakistan. The surgery using mixed reality (MR) technology was done in two stages and was highly successful. The twins are thriving, and expected to recover fully.

MR is breakthrough, cutting edge technology and combines 3D images with the physical world, which enables surgeons to rehearse the procedure through visualization. This increases the precision of this complex procedure, and gives hope to many other cases around the world and for the future.

There is a long list of conjoined twins from all corners of the world who have lived incredible lives, featuring fictionally or non-fictionally in films, e.g. “Alone” (2007), “Big Fish (2003), “Sisters” (1972), “Freaks” (1932), and many more.

It has mostly been established that if conjoined twins aren’t separated as infants, it’s dangerous to separate them when olde; if they’d lived together, they would die together.

One can only but admire these intertwined brave beings for forging a place for themselves in this world, creating success and triumphing over their unimaginable adversity.