Elsevier

World Neurosurgery

Volume 113, May 2018, Pages 78-81
World Neurosurgery

Historical Vignette
Neurosurgery on a Pregnant Woman with Post Mortem Fetal Extrusion: An Unusual Case from Medieval Italy

https://doi.org/10.1016/j.wneu.2018.02.044Get rights and content

Highlights

  • This analysis can help understanding pregnancy morbidity, mortality, and related medical treatments in the Italian Early Middle Ages.

  • The rare phenomenon of post mortem fetal extrusion (coffin birth) from a women treated with cranial trepanation was reported.

  • Evidence of osteogenic reaction can be microscopically and macroscopically detected on skeletal remains.

Trepanation is one of the most ancient and applied surgical treatments; several archaeologically documented cases are known, dated back from prehistory to the Middle Ages. This case study reports the anthropologic analysis of the skeletal remains of a young medieval woman and a fetus (Imola, Italy). The fetal remains were laid between her pelvis and lower limbs. A perforating injury was observed to her frontal bone. After assessing biologic profiles, we attempted to interpret the injury and to reconstruct possible circumstances of death.

The lesion seems commensurate with a surgical intervention; signs of an osteogenic reaction were detected at its edges. It can be hypothesized that the survival of the woman undergoing the surgery was approximately 1 week and the fetus extruded after the burial. Thus, this case represents a unicum, spreading more light on the history of neurosurgery during the Early Middle Ages in Europe.

Introduction

Trepanation is defined as a surgical intervention applied to scrape, cut, or drill one or more openings into the neurocranium,1, 2 and it is documented as the oldest type of neurosurgical intervention.2 Evidences of this practice in Europe has been documented,2, 3 but only a few of these are traceable to the Early Middle Ages, and in particular in regard to an Italian archaeological context.1, 4, 5, 6 Trepanation is known to have been applied since the Neolithic era as a surgical intervention aimed at treating several types of diseases, such as traumatic injuries or neurologic issues, and, in particular, migraines caused by high intracranial pressure or cerebral disturbances related to vascular pathologies.2, 4, 6 However, other than the presence of a head injury, it is impossible, in the majority of cases, to be certain of the specific reason behind trepanations identified in the skeletal remains.2

Considering the scarce archeo-anthropologic evidence of maternal mortality, even more interesting is the case study presented here as it concerns a pregnant woman with signs of a possible trepanation on the skull. Although maternal mortality has always affected women, its evidence is rare in skeletonized individuals, because only the presence of fetal remains in the mother's womb can attest to the pregnancy status of the woman.7

In the present study, we examined the case of a young woman from the Early Italian Middle Ages, discovered with her unborn child and a penetrating injury on her frontal bone. The focus of our study was to establish the possible cause of death of these individuals, and to evaluate whether the traumatic evidence could be interpreted as a trepanation attempt.

Section snippets

Materials and Methods

In 2010, several burials belonging to the Lombard period (7th–8th century ad) were found in Imola (Bologna district, Northern Italy); among these, there was a burial in a brick coffin containing the well-preserved skeletal remains of an adult and an immature human skeleton (Figure 1). The chronologic framing was assessed by stratigraphic and numismatic analysis; furthermore, the burial was found above the layer of a road dated to the 6th century, confirming its belonging to a period covering

Results

The skeletal remains belonged to a young woman and a fetus, whose main anthropologic characteristics are listed in Table 1. In the cranial vault of the woman, a penetration through a circular hole measuring 4.6 mm in diameter was observed (Figure 3A). This lesion pierced the center of the frontal bone along a line tangent to the medial margin of the left orbital cavity and almost at the apex of the cranial vault (Figure 3). The hole presents features that might have been caused by a

Discussion

This case led to many research topics and questions. First, we questioned the nature of the cranial lesion, whether it was inflicted with violent or medical purpose, and what kind of instrument could have caused such injury. We then wondered whether the injury itself was the cause death, or if it could have been somehow connected to a pregnancy-related medical treatment.

As for the first question, the lesion did not feature any radial or additional fractures around its circumference that could

Conclusions

The case of the pregnant woman from Imola shows a curious ensemble of rare anthropologic and paleopathologic findings, presenting a trepanation and a case of coffin birth at one time. Although the nature of the injury has been clarified, there are still several unknown points about the woman's cause of death. We hypothesize that the woman could have developed a labor-related complication, which indicated the surgical intervention, but still it is not possible to know whether the death incurred

Acknowledgments

The authors thank the Superintendence for the Archaeological Heritage of Emilia-Romagna for the permission to study these skeletons discovered at the Imola site, which are now located in the anthropologic collection of the Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Italy.

References (33)

  • D. Ferembach et al.

    Recommendation for age and sex diagnoses of skeletons

    J Hum Evol

    (1980)
  • J.E. Buikstra et al.

    Standards for data collection from human skeletal remains. Arkansas Archaeological Survey Research Series

    (1994)
  • W.M. Krogman et al.

    The Human Skeleton in Forensic Medicine

    (1986)
  • S.M. MacLaughlin et al.

    Vertebral body diameter and sex prediction

    Ann Hum Biol

    (1992)
  • G. Acsádi et al.

    History of Human Life Span and Mortality

    (1970)
  • C. Lovejoy

    Dental wear in the Libben population: its functional pattern and role in the determination of adult skeletal age at death

    Am J Phys Anthropol

    (1985)
  • Cited by (15)

    • Cranial Surgery in Italy During the Bronze Age

      2022, World Neurosurgery
      Citation Excerpt :

      A differential diagnosis of the skull lesion was undertaken to establish its nature and whether it was ante mortem, perimortem, or post mortem. Signs of healing and pathologies possibly related to the alleged surgery were analyzed.23,8,24-27 The survival rate after trepanation was analyzed while considering three healing conditions23: none (absence of any evidence of remodeling of the bone or bone regeneration, indicating non-survival or post mortem operation), short-term survival (presence of early osteoclastic and osteoblastic activity, indicating survival of several weeks); or long-term survival (evidence of extensive bone remodeling).

    • A multifaceted approach towards investigating childbirth deaths in double burials: Anthropology, paleopathology and ancient DNA

      2020, Journal of Archaeological Science
      Citation Excerpt :

      Today in developing countries the World Health Organization estimates an average of 239 deaths per 100,000, compared to only 12 in developed countries (WHO, 2019). However, despite the assumption that maternal and infant mortality was much higher in the past, evidence of this is lacking in the archaeological literature (e.g. Appleby et al., 2014; Cruz and Codinha, 2010; Dulias et al., 2019; Lieverse et al., 2015; Malgosa et al., 2004; Pasini et al., 2018; Rebay-Salisbury, 2018; Willis and Oxenham, 2013; Zhou et al., 2019). Attempts to identify maternal events in past populations have mainly focused on burials of females which appear to have died during pregnancy, childbirth, or soon after.

    • Post mortem fetal extrusion: Analysis of a coffin birth case from an Early Medieval cemetery along the Via Francigena in Tuscany (Italy)

      2020, Journal of Archaeological Science: Reports
      Citation Excerpt :

      The unusual position of the fetus, the opposite orientation to that of the mother and the not term pregnancy, but at 32 weeks of gestation, suggests that it is a case of “coffin birth”, i.e. a process of post mortem fetal extrusion. This phenomenon, which involves the expulsion of a non-living fetus from the body of the mother who died during pregnancy, has been documented both in the forensic (Panning, 1941; Schulz et al., 2005; Lasso et al., 2009) and archaeological fields (Rascón Pérez et al., 2007; Sublimi Saponetti et al., 2013; Appleby et al., 2014; Cesana et al., 2017; Pasini et al., 2018). In addition, it seems to mainly involve preterm fetuses, therefore relatively small, and with cephalic presentation (Schulz et al., 2005; Rascón Pérez et al., 2007; Lasso et al., 2009; Appleby et al., 2014).

    • Lucy's fatal childbirth? About materno-foetal mortality in the ancient times

      2020, Gynecologie Obstetrique Fertilite et Senologie
    • New Evidence of Prehistoric Neurosurgery in Italy: The Case of Castello Del Tartaro

      2019, World Neurosurgery
      Citation Excerpt :

      Evidence of trepanation is momentous in the archaeological record because it testifies the presence and evolution of neurosurgical practices throughout the history and prehistory of mankind; moreover, its association with other unusual findings is of particular interest, implying a peculiar context related to the practice itself.5 Recent studies have shown cases of trepanation associated with other remarkable conditions, usually related to clinical circumstances, such as childbirth,5 and therapeutic or posttraumatic treatments, both on human and animals3,6,15-22; some cases of postmortem trepanation have also been reported, in which the procedure has been linked to pharmacologic or thaumaturgic practices.23 The association of peculiar funerary practices with evidence of trepanation could also represent a significant finding.

    View all citing articles on Scopus

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    View full text