Luca Ventura, Vincenzo Urbani*, Alessandro Ricci**, Renato Galzio**, Mariano De Vito, Sandro Fantini*, Gino Fornaciari***.

Department of Pathology, San Salvatore City Hospital, L’Aquila, Italy;
*Department of Radiology, Villa Serena Clinic, Città S. Angelo (PE), Italy;
**Department of Neurosurgery, San Salvatore City Hospital, L’Aquila, Italy;
***Division of Paleopathology, Department of Oncology, Transplants and Advanced Technologies in Medicine, University of Pisa, Italy.

Keywords: Navelli – mummies – subdural hematoma – paleoneuropathology.

The church of San Sebastiano in Navelli (inner Abruzzo region, Central Italy) contains hundreds of mummified and skeletonized bodies, presumably ranging from XVI to XIX century (Ventura, et al., 2001; Ventura, et al., 2002). They were accidentally discovered in the crypts beneath the church in 1980 and, since then, only a preliminary report has been made (Capasso & Di Tota, 1991). Navelli is considered one of the most numerous series of italian mummies (Aufderheide, 2003).
During the first campaigns of excavation (years 2001 and 2004) the recovery yielded the remains of 206 individuals, in different conditions of preservation. The series includes 157 adults (102 males, 42 females, 13 indefinite) and 49 children (23.78%) (Ventura et al., 2005).
No macroscopic evidence of internal organs was observed in mummified subjects, whereas skin, skeletal muscles and other superficial tissues (eyes, ears, hair) appeared well preserved, suggesting that desiccation had a preminent role in the mummification process (Aufderheide, 2003).
Limited examples of mummified animals were also recovered, confirming the environment capability in the preservation of the tissues.
The initial paleopathologic analysis allowed to identify various pathologic conditions, including degenerative joint disease, periodontal disease, healed bone fractures, occasional tumors and a hydrocephalus. We could also recognize traces of post-mortem examination in a partially mummified young adult male, dead of uncertain causes (Ventura, et al., 2005; Ventura, et al., 2006).

Material and methods
One of the infant subjects (NSS 513) was a well-preserved mummy, wrapped in rough grey fabric bands and wearing a fine headcap (Fig. 1).
After the external examination, a radiologic (RX) and computed tomography (CT) study was performed at the Department of Radiology of the Villa Serena Clinic, Città S. Angelo, by using a Philips Brilliance CT scanner with 1 mm thick sections, obtained at reconstruction intervals of 0.5 mm.
Further investigations including endoscopy, histologic and ultrastructural examination, as well as DNA sex determination are planned to obtain additional information.

The subject was a well-preserved, complete, infant mummy, spirally wrapped in rough grey fabric bands and wearing a fine headcap, easily removable from the head. The only visible parts of the body were the partially skeletonized face and the feet, showing good preservation of skin and soft tissues. The body measured 56.2 cm in length.
RX and CT examination revealed a two-button tunic probably belonging to a female. CT scanning allowed to establish 9 + 3 months as the age at death, estimating a corrected stature of 60 cm.
Radiologic examination also displayed an increased biparietal diameter with frontal bones thinning and fully opened cranial sutures, a postural pattern related to spastic tetraparesis, a dorsal skoliosis, without signs of skeletal trauma (Figg. 2-4).
CT scanning highlighted the presence of amorphous material in the posterior cranial fossa, with no evidence of internal organs in thoracic and abdomino-pelvic cavities. Bilateral frontoparietal intracranial membranes were noted, leading to the diagnosis of chronic subdural hematoma (SDH) (Fig. 5).

The mummy belonged to an infant presenting clear signs of endocranial hypertension and spastic tetraparesis, but no evidence of skeletal trauma. The presence of bilateral frontoparietal intracranial membranes yielded the diagnosis of SDH.
SDH has been regarded in infants as a cardinal sign of inflicted injury (shaken baby syndrome). In modern cases, shaken baby syndrome is characterized by a constellation of clinical findings including subdural bleeding, retinal hemorrhage, and associated fractures of the extremities or ribs, with no external evidence of cranial trauma (Uscinski, 2006; Kujiraoka et al., 2004). Acceleration-deceleration stress is known to be the cause of subdural injury, because the bridging veins can easily be torn during shaking in young babies (Kujiraoka et al., 2004). In fact, the relatively large head and puny neck muscles of infants make them particularly vulnerable to whiplash injury and, for the same reasons, infantile SDH is often bilateral (Uscinski, 2006).
SDH has been regarded as a cardinal sign in infants with inflicted injury, but even head impacts occuring after a fall of a short distance are not innocuous events (Uscinski, 2006). While acute SDH is tipically seen after an obvious impact, chronic SDH starts acutely, but by definition its presence is either not recognized or its significance is not appreciated at the time of injury. For an infant presenting with unexplained intracranial bleeding without external evidence of trauma, accidental injury from a seemingly innocuous fall or even an occult birth injury, must be considered before assuming intentional injury (Uscinski, 2006).
Paleopathological cases of SDH were previously described in women and children belonging to a south american population, known for having suffered from beatings and head blows (Gerszten & Martìnez, 1995). Despite the absence of skeletal traumatic lesions, the present case is in strict analogy with those described in literature. The chronic character of the lesion is confirmed by the long time necessary for the development of secondary lesions such as spastic tetraparesis and endocranial hypertension. The absence of cranial and post-cranial skeletal trauma suggest the hypotesis of a shaken baby syndrome, but accidental injury may not be excluded.
Further investigations including endoscopy with intracranial membranes sampling, histologic and ultrastructural examination, as well as DNA sex determination are planned to obtain additional information and confirm the diagnosis. It is impossible to determine with scientific rigor the precise cause of head injury in the reported case.

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The recovery of the Navelli mummies was made through the efforts of the “Associazione Paleopatologica Aquilana” and partially supported by a grant from the “Consorzio Beni Culturali Provincia L’Aquila”.

Fig. 1. Frontal view of the mummy.


Fig. 2. Standard antero-posterior radiograph showing fully opened cranial sutures (endocranial hypertension).


Fig. 3. Standard lateral radiograph showing bone thinning and two metallic artifacts (tunic buttons) in the posterior cervical surface.


Fig. 4. Standard antero-posterior radiograms of the mummy, showing spastic tetraparesis and dorsal skoliosis, without signs of skeletal trauma.


Fig. 5. Computed tomography scans of the head with bilateral frontoparietal membranes, related to subdural chronic hematomas.