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.

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    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.

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