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  Although many chroniclers include the twins in their histories, we present Ioannes Skylitzes' version of the event. Between 1126 and 1150, Skylitzes endeavored to write a history of the Byzantine Empire from 811-1057. It was not uncommon for medieval Greek historians to draw on pre-existing work and Skylitzes' sources consist of past manuscript histories written by a series of Middle Byzantine chroniclers called Theophanes Continuatus, Chronographia ("A Description of Time"). The extent to which Skylitzes modified his history likely only involved paraphrasing previously written sources. His account of the twins and their surgery is no different; it is secondhand information that comes from a brief version of Theophanes Continuatus’ description of the case. 
  
  This folio of the manuscript portrays the first recorded attempt to surgically separate conjoined twins, complete with images from before and during the procedure. The first mention of the twins' arrival in Constantinople was in the 940s during the reign of Emperor Romanos I Lekapenos (920-44); at this time they were between four to twelve years of age. Little else is known about their personal lives other than that they hailed from Armenia. When they arrived in Constantinople, Skylitzes reported that people feared that their appearance indicated evil to come, and exiled them from the city. They were forced to return, however, during Constantine VII’s reign as emperor when, at about thirty years old, one of the twins died and the surviving twin needed surgery to separate him from his brother. The surviving twin’s decision to return to the Byzantine empire despite his previous expulsion may be a testament to the comparatively advanced medical care that he felt he could receive there. 
  
  Given their similarities in style, the same artist most likely produced both illuminations. The illustrator exercised artistic license in his portrayal of the twins, as they are inaccurately depicted as attached on the back, chest, and back of the head, respectively. However, conjoined twins of this type (pygopagus-thoracopagus-cephalopagus) have not been found before in humans. Furthermore, the bottom illustration shows the dead twin being much smaller than the surviving twin, which contradicts Theophanes Continuatus’ description of their limbs being “completely grown." 

  About the Twins

  The twins were from Armenia, but their ventures around Constantinople brought onlookers' attention. One account by Leo the Deacon describes the twins as hailing from Cappadocia. He saw the twins often when he returned home and reported that they frequently travelled around the empire. However, it is unclear whether these are the same conjoined twins described by the Theophanes Continuatus authors and Skylitzes. Leo the Deacon recounted the twins as "being indescribably kind in mind and virtuous" (γλυκυθυμία καὶ ἐπιείκεια). Despite this description, Skylitzes wrote that they were expelled from Constantinople for fear that they represented an evil omen. 
   

  Disability in the Middle Ages 

  Medieval Christians perceived disability as God's punishment for sins committed by the disabled children's parents. People also believed that disability was the result of sexual misconduct when the child was conceived, including conceiving while in an improper position, the woman moving during sex, either the man or woman (but mostly the woman) letting their thoughts wander, eating certain foods during pregnancy, conceiving during menstruation, pregnancy, or lactation, and the woman not resisting sexual advances from her partner when it was not proper time to conceive. Due to these widespread beliefs it wasn’t uncommon for disabled people (and probably their parents as well) to be rejected from society and seen as omens of bad luck or evil, as was the case with the twins. 
  
  However, sometimes Christians welcomed disabled people, believing that their suffering made them closer to God. The non-disabled also perceived the disabled as an opportunity to perform charitable acts that could lead to their entry in heaven at the time of their death. Since the twins wandered throughout Asia and there weren’t many work opportunities available for disabled people in the Middle Ages, it is likely that they survived from charitable acts. In the Middle Ages, disabled people could either be fools, live with their family, live from charitable acts, or become beggars. Neither the Madrid Skylitzes nor other accounts of the twins mention them traveling with any companions, and do not mention whether the twins acted as beggars in any of the places that they visited, which could suggest that the people they encountered would provide them with charitable acts.

  The Procedure 

  In 945, one of the twins died. The cause of that twin’s death is unknown, and it is also unclear how long the surviving twin remained attached to his brother before seeking medical help in Constantinople to separate them. Scholars disagree regarding the type of conjoined twin category under which these two fall. Erwin J.O. Kompanje judges that the the brothers were xiphopagus conjoined twins. These types of twins are rare, and today they generally carry a good prognosis of separation. This prognosis stems from the fact that this class of conjoined twins are joined together only by cartilage and soft tissue at the xiphoid process, which is a bony formation located at the bottom of the sternum. As such, they do not share vital organs, making separation easier. The rate of survival for these type of twins is especially high compared to other kinds of conjoined twins, which explains why the twins were able to survive as long as they did.  
  
  Conversely, S. Geroulanos, F. Jaggi, J. Wydler, M. Lachat, and M. Cakmakci argue that the twins were thoracopagus conjoined twins. These types of conjoined twins are one of the most common. Thoracopagus twins are fused together at the anterior chest, so the twins face each other. This type of malformation includes a fused heart, which makes separation much more complicated. While the degree of jointness varies among twins with this diagnosis, Geroulanos et al. report that the twins shared a large part of their chest, and this jointness extended to their lower abdomen. 
  
  According to Skylitzes, the experienced surgeons in Constantinople endeavored to separate the twins. Geroulanos et al. argue that the surgeons’ attempt to perform the surgery despite its risks demonstrates their confidence in their abilities. While this may be true, surgeons during this period were generally cautious while performing surgery, confining their operations to the exterior surface of the body or natural openings in the body such as the nose or genitalia. It follows then that no instructions for a similar operation were available in medical literature of the time. 
  
  The Madrid Skylitzes depicts several surgeons attempting the separation. These surgeons likely belonged to the “professional” class of medical practitioners who were dedicated to surgery alone. Professional surgeons sought to keep their profession exclusive and prevent lower status “surgeons” from taking their medical knowledge and techniques. In the illustration, the surgeons cut the twins apart where they were joined together at the midsection with a surgical knife. Afterwards, it is likely that the abdominal wound was sutured together, as a full-thickness stitching method was used by Byzantine physicians as early as the fourth century. In the tenth century, no reliable form of anesthesia existed, so the surgeons likely operated hastily to minimize the pain the surviving twin inevitably experienced. Both Skylitzes and the Theophanes Continuatus authors report that the still-living twin survived for three days until passing away.

   

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  Footnotes

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  1. G.E. Pentogalos and John G. Lascaratos, "A Surgical Operation Performed on Siamese Twins During the Tenth Century in Byzantium," in Bulletin of the History of Medicine 58, no.1 (1984), 100.↵
  2. S. Geroulanos et al., “Thoracopagus symmetricus. On the separation of Siamese twins in the 10th century A. D. by Byzantine physicians” in Gesnerus 50 (1993), 195.↵
  3. Madrid, Biblioteca Nacional de España, MS Vitr. 26-2, f. 131r.↵
  4. Pentogalos and Lascaratos, "A Surgical Operation Performed on Siamese Twins,” 100. ↵
  5. Ibid., 100.↵
  6. Theophanes Continuatus, Chronographia, VI.49, Corpus scriptorum historiae byzantinae, 45: 433. ↵
  7. Anthony Kaldellis, A Cabinet of Byzantine Curiosities. (New York, NY: Oxford University Press, 2017), 70.↵
  8. Irina Metzler, “Disabled Children: Birth Defects, Causality, and Guilt” in Medicine, Religion and Gender in Medieval Culture, ed. Naoë Kukita Yoshikawa (Rochester, N.Y.: Boydell & Brewer, 2015), 161-180.↵
  9. Metzler. “Disabled Children,” 166, 168, 171, 179, 165.↵
  10. Joshua Eyler, "Introduction," in Disability in the Middle Ages: Reconsiderations and Reverberations, ed. Joshua Eyler (Farnham: Taylor & Francis Group), 3-4.↵
  11. Irina Metzler, Fools and Idiots?: Intellectual Disability in the Middle Ages (Manchester: Manchester University Press, 2016), 186.↵
  12. Metzler, Fools and Idiots?, 188.↵
  13. Erwin J.O. Kompanje, "The First Successful Separation of Conjoined Twins in 1689: Some Additions and Corrections," Twin Research and Human Genetics 7, no. 6 (2012), 540.↵
  14. Gowri Dorairajan, “Undiagnosed xiphopagus twins: A perinatal malady,” Clinics and Practice 2, no. 23 (2012), 52.↵
  15. Pentogalos and Lascaratos, "A Surgical Operation Performed on Siamese Twins,” 102.↵
  16. Geroulanos et al., “Thoracopagus symmetricus,” 182.↵
  17. Mehmet A. Osmanagoaglu, “Thoracopagus Conjoined Twins: A Case Report,” ISRN Obstetrics and Gynecology 2011 (2010): 1.↵
  18. Geroulanos et al., “Thoracopagus symmetricus,” 183.↵
  19. Ibid., 199.↵
  20. Nancy Siraisi, Medieval & Early Renaissance Medicine: An Introduction to Knowledge and Practice (Chicago, IL: University of Chicago Press, 1990), 155.↵
  21. Lawrence Bliquez, “Two Lists of Greek Surgical Instruments and the State of Surgery in Byzantine Times,” Dumbarton Oaks Papers 38 (1984), 194.↵
  22. Peter Murray Jones, “John of Arderne and the Mediterranean Tradition of Scholastic Surgery,” in Practical Medicine from Salerno to the Black Death, ed. Luis García Ballester et. al. (Cambridge, MA: Cambridge University Press, 1994), 304. ↵
  23. John Lascaratos, “Fatal Wounding of the Byzantine Emperor Julian the Apostate (361-363 A.D.): Approach to the Contribution of Ancient Surgery,” World Journal of Surgery 24 (2000), 617.↵
  24. Pentogalos and Lascaratos, "A Surgical Operation Performed on Siamese Twins,” 102.↵