S HO R T R E PO R T
An unprecedented case of cranial surgery in Longobard Italy
(6th–8th century) using a cruciform incision
Ileana Micarelli1 | Flavia Strani2,3 | Samuel Bedecarrats4 |
Sara Bernardini5,6 | Robert R. Paine5 | Lawrence Bliquez7 | Caterina Giostra8 |
Valentina Gazzaniga9 | Mary Anne Tafuri5 | Giorgio Manzi5
1McDonald Institute for Archaeological Research, University of Cambridge, Downing St, Cambridge, CB2 3ER, UK
2Departamento de Ciencias de La Tierra, and Instituto Universitario de Investigaci
on en Ciencias Ambientales de Arag
on (IUCA), Universidad de Zaragoza, Zaragoza,
50009, Spain
3Department of Earth Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
4UMR 6273 CRAHAM, CNRS, Université de Caen Normandie, Esplanade de la paix, Caen cedex 5, CS, 14032, France
5Department of Environmental Biology, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
6Aix Marseille Univ, CNRS, Minist Culture, LAMPEA, Aix-en-Provence, France
7Department of Classics, University of Washington, Seattle, Washington, 98195-3110, USA
8Department of History, Archaeology and Art History, Università Cattolica del Sacro Cuore, Lrg. Agostino, Gemelli 1, 20123, Milan, Italy
9Department of Medico-Surgical Sciences and Biotechnologies, Sapienza, University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
Correspondence
Prof Giorgio Manzi, Department of
Environmental Biology, Sapienza, University of
Rome, Piazzale Aldo Moro 5, 00185 Rome (IT).
Email: giorgio.manzi@uniroma1.it
Dr Ileana Micarelli, McDonald Institute for
Archaeological Research, University of
Cambridge, Dowining St, CB2 3ER, Cambridge,
UK.
Email: im452@cam.ac.uk
Funding information
HORIZON EUROPE Marie Sklodowska-Curie
Actions, B-CARED Osteobiographical
investigation of disability and care in Medieval
Europe, Grant/Award Number: 101061838;
Source of support: “Population biology,
diseases and mobility: Romans and Longobards
in the post-classical era”, Grande Progetto
Sapienza 2018, RG118164364E4CB5.
Abstract
The Longobard necropolis of Castel Trosino dates from the 6th to the 8th century
CE. Among the tombs excavated, the skull of an older female shows the first evidence
of a cross-shaped bone modification on a living subject. Macroscopic, microscopic,
and CT scan analyses revealed signs of at least two sets of scraping marks.
Specifically, SEM analysis shows that perimortem bone-scraping traces are present on
the skull. Both healed and non-healed defects suggest that the woman has received
at least twice intentional bone modifications to address her condition. This is the first
evidence of a cross-shaped therapeutic intervention on a living subject.
K E YWORD S
bioarchaeology, CT scan, paleopathology, SEM analysis, skull defect
1 | INTRODUCTION
Cranial defects constitute a significant interpretative challenge for
osteoarchaeologists. They may be hidden by the proliferative or
resorptive bone response (Verano, 2017). To improve the quality of
the interpretation of defects, it is critical to approach this process with
a differential diagnosis perspective and contextualize findings
with historical medical documents and the archeological record
Ileana Micarelli, Flavia Strani, and Samuel Bedecarrats contributed equally.
Received: 5 September 2022 Revised: 13 January 2023 Accepted: 16 January 2023
DOI: 10.1002/oa.3202
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. International Journal of Osteoarchaeology published by John Wiley & Sons Ltd.
Int J Osteoarchaeol. 2023;1–9. wileyonlinelibrary.com/journal/oa 1
(e.g., Aidonis et al., 2021). Using a multidisciplinary approach, we pre-
sent unprecedented evidence specific to several cranial defects
observed in one female skull.
The remains were excavated from the Longobard cemetery of
Castel Trosino, contrada Santo Stefano (Figure 1a,b) in central Italy,
dated to the Early Middle Ages (Ascoli Piceno, 6th–8th century CE;
Ricci & Paroli, 2007). The cemetery was investigated at the end of the
19th century (Mengarelli, 1902; Sergi, 1902). Hundreds of burials
were recovered, but only 19 skulls are available for assessment
(Micarelli et al., 2021).
Castel Trosino was a critical site in the complex political situation
that developed after the collapse of the Roman Empire (postclassical
period). After losing Po Valley territories, the Byzantine government
stabilized military control of central Italy. As a result, during the 6th
century CE, Castel Trosino became a strategic site. The archeological
literature (Delogu, 2016; Ricci & Paroli, 2007) describes the site as
having a non-preeminent military function. The first Longobard phase
at Castel Trosino began during the last decade of the 6th century
(Jørgensen, 1991; Ricci & Paroli, 2007). Most likely, this phase was
established by a small group of warriors led by high-ranking military
leaders who were given the insignia of Imperial Generals
(Delogu, 2016). They aimed to compensate barbarian leaders associ-
ated with the Imperial government and ensure regional peace. To do
so, the Byzantine authorities encouraged the occupation of Castel
F IGURE 1 (a) Location of Castel Trosino
(Ascoli Piceno, Italy); (b) map of the necropolis in
the contrada Santo Stefano. Burial T67 is in red.
Image modified from Ricci & Paroli, (2007),
Figure 2, p.10. [Colour figure can be viewed at
wileyonlinelibrary.com]
2 MICARELLI ET AL.
Trosino by Longobard elites (Delogu, 2016; Jørgensen, 1991;
Profumo & Staffa, 2007; Ricci & Paroli, 2007). Castel Trosino became
the residence of several prestigious families, as indicated by
exceptional grave goods (gold objects and fine jewelry). As unique
postclassical Italian grave goods, these pieces are primarily
Roman-Byzantine manufactured and correspond to the customs of
Byzantine and Longobard societies (Delogu, 2016).
2 | MATERIALS AND METHODS
Skull CT1953 was found in a double burial (T67) at the Christian
Church exterior façade in the center of the cemetery. Grave
goods included a bronze brooch, comb, and gold filaments
(Mengarelli, 1902). The burial location and the richness of the grave
goods suggest that the two owners (a male and a female; Micarelli
et al., 2021) come from a privileged family (Delogu, 2016). The skull is
well-preserved; the surface morphology is intact, with no modifica-
tions caused by taphonomic processes (Figure 2).
A biological profile of the skull was conducted following standard
anthropology protocols. Sex was determined via cranial morphological
traits (Buikstra & Ubelaker, 1994), and the age at death was estimated
by examining cranial sutures (Meindl & Lovejoy, 1985) and dental
occlusal wear (Walker et al., 1991).
2.1 | Methods for the analysis of the bone marks
A gross pathological assessment was conducted to document the cra-
nial defects (Kranioti, 2015; Lovell, 1997; Redfern & Roberts, 2019).
Two acquisitions of the skull from CT1953 (Figure 2) were per-
formed at the Istituto Superiore di Sanità in Rome (IT) via cone beam
CT scan (NewTom 5GXL EXTRA.VISION) using a protocol adapted to
bone analysis (slice thickness: 0.3 mm, 110 kVp). Virtual reconstruc-
tion of the scan was performed on a 611 
 692 
 539 pixel matrix
(Schindelin et al., 2012).
We molded the scraped areas using a nondestructive and
conservation-friendly technique for investigating skeletal remains
(see Camar
os et al., 2016). We analyzed epoxy resin casts via
scanning electron microscope (SEM). Following a standard protocol
(Strani et al., 2018), we prepared casts of the bone defects on the
CT1953 skull (the complete procedure is described in Figure 3).
3 | RESULTS
Cranial morphology indicates that the skull is female, approximately
50 years old. The macroscopy investigation showed a cross-shaped
area of porous bone on the external surface of the cranial vault, with
an oval-shaped depression at the center of the cross. The anterior
frontal bone shows a second oval-shaped scraped area. These are
described in detail in Table 1. Moreover, two abscesses (one involving
the alveolus of RI1 and RI2 and the other affecting the LI2; Figure 2a)
and antemortem tooth loss (right maxilla: RI1, RI2, RC, LM3; and left
maxilla: LI1, LI2, LC, LP1, LP2; Figure 2a) were also observed and illus-
trated (Figure 2a,b).
The CT scan analysis showed a thickening of the diploe in the
frontal area, which presents a significant width (10 measurements:
mean 21.50 mm, min 15.3, max 26.72). This is considered abnormal
compared to modern populations (e.g., Şakir Eks¸i et al., 2021 repre-
sent 8.7 mm for women). This change may reveal the first phase of
hyperostosis frontalis interna (HFI), a condition that appears commonly
in female individuals during menopause (at century 50 years old)
(Cvetkovi
c et al., 2020; Figure 4a). This differential diagnosis can be
F IGURE 2 Skull CT1953
from burial T67. (a) Frontal view.
The black arrow indicates the
large oval scraped area on the
frontal bone. The white arrows
show the abscesses involving RI1
and RI2 and LI2. (b) Superior
view. The black arrow indicates
the circular ectocranial
depression near bregma. The
white arrows show the cross-
shaped scraping parallel to the
sagittal and coronal sutures.
MICARELLI ET AL. 3
related to a calvaria thickening or HFI. However, considering that the
skull does not have the large bone nodules typical of HFI (Hershkovitz
et al., 1999), we cannot consider HFI the only possibility. Although
the individual's biological profile tends to favor this hypothesis, other
conditions such as an idiopathic form, Paget's disease, sclerosing dys-
plasia, acromegaly, or a hematopoietic disorder cannot be excluded.
The absence of clear signs and the impossibility of an exhaustive
examination of the skeleton do not allow the differential diagnosis to
be refined.
The CT scan shows sagittal fissures in the middle of Defect E
(black arrows in Figure 4b, white arrow and white square in Figure 4d)
and endocranial and ectocranial bone thinning correspondingly with
the circular depression near bregma (white arrow and white square in
Figure 4d).
Recent cut marks are recognized via SEM analysis of the defects
(Figure 5). The V-shaped marks have a profound deep point with
sharp edges (Table 1; Figure 5a,b arrows), suggesting a perimortem or
postmortem event.
4 | DISCUSSION
Pitting and periosteal new bone formation on the external table of
cranial vault suggests changes secondary to inflammation (Figure 2b).
The cut marks seen on visual inspection, and scanning electron
microscopy would indicate that metal surgical tools were used. A plau-
sible interpretation of these changes would be that a cross-shaped
incision had been made to the top of the head by a medical practi-
tioner, and the scalp scraped away from the bone, stimulating inflam-
mation. If infection of the wound occurred, this would add to the
inflammation. The oval area at the center of the cross appears to be a
well-healed scraped trepanation.
The use of several shaped instruments and medical procedures
are well-documented (Bliquez, 2014). Medical instrumentations and
the methods of their use were passed almost unchanged from Greek
to Arabic and Byzantine literature. Instruments and treatments were
standardized and remained unchanged throughout the Middle Ages
(Gazzaniga & Marinozzi, 2015). Various drilling techniques were used
F IGURE 3 Molding and casting process on CT1953 skull. (a) The bone surface is cleaned by wiping with cotton swabs moistened with
acetone (≥99.5%). Then, acetone was removed by ethanol and left to dry completely. (b) The silicone was applied to the bone defects with the
dispensing gun (blue silicone). As Camar
os et al. (2016: 4) recommended, another layer of silicone is added to cover it (the orange one in the
picture). (c) The casts were laid following the anatomical position and marked to distinguish them. Silicone walls (in orange) were added to contain
the transparent epoxy resin (araldite LY 554) and catalyst (HY 956) for the positive casts. We left the transparent epoxy resin for 48 h in a dry
place. (d) The casts passed through the metallization of the surface with golden powder. (e) The sample was examined with SEM at the
Department of Scienze della Terra, Sapienza, University of Rome. [Colour figure can be viewed at wileyonlinelibrary.com]
4 MICARELLI ET AL.
for curative purposes. Both Celsus (1st century) and Paul of Aegina
(7th century) describe in their respective medical treatises the scrap-
ing of the skull with a sharp-edged metal tool as a trepanation
procedure (González-Darder, 2019). Constantine the African, in his
“Surgery” (chapter 92), was the first mentioning cross-shape scalping
(Perrot, 1982). The 12th century Book I of Practica Chirurgiae by
TABLE 1 Description of defects for a differential diagnosis
Defect on the skull
Bone
involved Description of the defect Measurements Bone reaction
The oval defect on the
frontal bone
Frontal
bone
A large oval area runs laterally across the
central portion of the frontal bone.
Length: 43 mm
Max width:
16 mm
Healed:
Visible to the naked eye;
Figure 2a, black arrow
Defect A Frontal
bone
Oval branch on the upper part of the frontal
squama. This defect runs anterior to
posterior. It has a hollowed ridge of bone
in the center, whereas the outer edges
are deeply marked.
Length: 40 mm
Max width:
11 mm
Healed:
Bone reaction with the osteoblastic and
osteolytic remodeling in the entire
area of the defect (visible to the naked
eye; Figure 2b, white arrow)
No healing process:
Marks with sharp edges and sharp edges,
V-shaped sections. The marks run
parallelly and perpendicularly
(SEM images; Figure 5a, black arrows)
Defect B Right
parietal
The defect runs parallel to the coronal
suture. This lesion is perpendicular to
Lesion C.
Length: 60 mm
Max width:
10 mm
Healed:
Bone reaction with the osteoblastic and
osteolytic remodeling in the entire
defect area (visible to the naked eye,
Figure 2b, white arrow)
No healing process:
The marks run parallel to each other
(SEM images).
Defect C Right
parietal
Defect C runs parallel to the sagittal suture.
Lesion C has a raised line of remodeled
compacted bone (30 
 5 mm)
Length: 60 mm
Max width:
8 mm
No good quality SEM picture to
determine the healing process
Defect D Left
parietal
Defect D runs parallel to the coronal suture.
At the most lateral part, there is a small,
raised surface (10 
 5 mm)
Length: 60 mm
Max width:
11 mm
Healed:
Bone reaction with the osteoblastic and
osteolytic remodeling in the entire
area of the defect (visible to the naked
eye; Figure 2b, white arrow)
No healing process:
Marks with sharp edges and sharp edges,
V-shaped sections. The marks run
parallelly and perpendicularly (SEM
images; Figure 5b, black arrows)
Defect E Right
parietal
At the intersection of the A, B, C, and D
defects, there is an oval-shaped defect at
1 mm from the sagittal suture and 8 mm
from the coronal one. The center portion
is more profound than the outer edge
(minus 1,5 mm from the external tables of
the skull). In the middle of lesion E, two
tiny holes lead into the braincase (hole a
0,5 mm in diameter; hole b 1 mm in
diameter). There are three small
osteophytes on the border of the deep
lesion: Osteophyte (i) on the left board
1,5 mm in diameter; osteophyte (ii) on the
frontal board 2 
 8 mm; osteophyte (iii)
in the middle 3 
 2 mm: (Figure 4b).
There are two fissures in the middle of
the Defect E: (Fissure I) 2-mm long;
(Fissure II) 1-mm long.
Length: 20 mm
Max width:
15 mm
Healed:
Bone reaction with the osteoblastic and
osteolytic remodeling in the entire
area of the defect (visible to the naked
eye; Figure 2b, white arrow)
No healing process:
Marks with sharp edges and V-shaped
sections. The marks run parallelly and
perpendicularly
(SEM images; Figure 5c, black arrows)
MICARELLI ET AL. 5
Roger Frugard, which incorporates Greco-Roman medical traditions,
describes the X-shaped incision as a regular way of clearing the scalp
to get to the cranium.
The endocranial thinning of the cranial vault near bregma
(Defect E, Figure 4d’) shows rim formation and bone loss of the
diploic structure (Figure 4d), suggesting significant healing. This can
F IGURE 4 Virtual analyses of the skull CT1953. (a) CT scan of the skull (left view). The arrow shows the diploe of the frontal area;
(b) magnification of the circular ectocranial depression near bregma, labelled in Table 1 Defect E, external view. The white arrows indicate the
osteophytes, and the black ones shows the fissures, described in Table 1; (c) X-rays of the skull, right side; (d) sagittal view of the skull CT scan.
The white arrow indicates the thinning of the bone (endocranial and ectocranial) in correspondence with the circular depression near bregma. D’)
shows the opening into the skull. D”) black arrows indicate the presence of lithic lesions. [Colour figure can be viewed at wileyonlinelibrary.com]
F IGURE 5 SEM analyses of the skull CT1953. Arrows indicate incision by a sharp object showing no remodeling. (a) Defect A; (b) Defect C;
(c) Defect E
6 MICARELLI ET AL.
be linked to several conditions. Among them, we considered
(i) perforating trauma results from the severe impact on the skull. This
may cause the break of the inner table of the skull and, eventually,
fracture lines running from the injury (Nerlich et al., 2003; Rubini &
Zaio, 2011). Given the impact and the open fracture in the skull, these
lethal traumas often lead to death. This is not the case for CT1953;
(ii) neoplastic pathologies (e.g., multiple myeloma and metastatic carci-
noma): the absence of the typical destructive lesions (e.g., sunburst,
scalloped, and edges) and the lack of multiple lesions (Marques, 2019;
Figure 4c and Table 1), suggest eliminating this hypothesis; (iii) middle
meningeal artery (MMA) aneurysm: can be excluded given the posi-
tion of the lesion (Riccomi et al., 2022); (iv) arachnoid granulations:
their shape and location, mainly along the transverse or superior
venous sinuses, may lead to excluding this condition for CT1953
(Gomez et al., 2018). However, arachnoid granulations can also be
related to meningiomas. In these cases, granulation is often found at
the bregma (Ye et al., 2022). The endocranial thinning of the CT1953
skull might be related to this condition (Figure 4d”).
The abscesses on the maxilla severely affected the pulp cavity,
causing infection and resorption of the maxillary bone. Dental
abscesses and antemortem tooth loss likely indicate poor oral health
(Larsen, 2015).
Given the absence of the mandible and the rest of the skeleton, it
is challenging to diagnose a pathological condition. However, the
presence of porosity on the skull surface and the lesion on the ecto-
cranial surface suggests a systemic pathological condition that
affected CT1953 during her life. Illness linked to chronic headaches
and neurological, mental, or behavioral disorders is impossible to ver-
ify from the bones (Gresky et al., 2016).
CT1953 shows two sets of defects:
i. Antemortem: bone response is present and visible to the naked
eye (Figure 1a,b). Signs of remodeling, such as osteophyte and/or
bony bridges, are the first bone response, indicating short-term
survival (1–3 weeks up to 2.5 months after sustaining an injury).
Long-term survival is supported by smooth bone surface. This
occurs after 6 months (e.g. Barbian & Sledzik, 2008).
ii. Perimortem: V-shaped marks indicate interventions close to death
(Table 1; black arrows in Figure 5). Up to 5–7 days after the inter-
vention, the edges of the marks are sharp without osteoclastic
resorption or bone formation (Kranioti, 2015). No bone healing is
present for these bone marks on the CT1953 skull. Moreover,
the repetitive movements by a practitioner created perimortem
intersecting scraping mark on the skull surface (black arrows in
Figure 5).
Redfern and Roberts (2019) suggest that intentional superficial cranial
changes with a non-penetrated cranial vault are infrequently reported
in the literature (e.g., the T-sincipital described by Manouvrier in
1895). Following Verano (2017: 2), scraping trepanations consist of
gradually removing the outer table and diploe. When the inner table is
exposed, it can be scraped or broken out. We support the argument
that the bone marks on the CT1953 skull are a series of voluntary
actions (i.e., the oval defect on the frontal bone, Figure 2a; Defects A,
B, C, D, and E Figure 2a,b; Table 1). These were planned, and an oper-
ator intentionally conducted recurring bone modifications. Given the
extension and the voluntary repetition of the interventions and the
presence of the fissures in the cranial vault following the Western
nomenclature (Lisowski, 1967), we define the oval-shaped Defect E as
a trepanation obtained via the cruciform surgical incisions (Defects A,
B, C, and D). Drilling and scraping the skull did not always mean pene-
trating through the dura mater, as in some cases, ancient trepanations
were designed not to create an opening in the skull (Bliquez, 2014:
186). Greco-Roman medical literature offers examples of more super-
ficial skull drilling or scraping to treat decaying cranial tissue or tere-
donismos (Oribasius, Coll. Med. 46.22.16; Heliodorus), excessive
callus as a sequela to fracture (Paul 6.108.1), and excessive bone
growth (Oribasius, Coll. Med. 46.29.8; Heliodorus). Correction of
these situations required drills, chisels, and rugines/curettes. Oribasius
indicates this when he recommends promoting the growth of flesh
after head trauma by first scraping to the diploe “with an ordinary/
common scraping tool” (διὰ κοινοῦ ξυστῆρος; Coll. Med.46.9.5).
To further explore an alternative rationale for the cranial scraping,
we considered ritualistic/sacral trepanations used by the Avar people
in the Carpathian basin during the 6th and the 11th century CE
(Bereczki et al., 2015; Király et al., 2022; Mednikova, 2003). Following
this archeological example, the Longobard people of Castel Trosino
and Byzantine culture are tightly intertwined (Ebanista & Rotili, 2010).
Although the symbolic hypothesis is fascinating, no documented or
archeological evidence supports that ritualistic trepanation practice
was borrowed from Eastern Barbaric for CT1953.
We also considered that the scraping might be related to judicial
punishment, namely, decalvatio, as written in Longobard law
(Gasparri & Azzara, 2011). This penalty was of particular gravity and
rarely applied (Longobard laws: King Liutprando: law number 141, and
King Astulf: law number 4). It entailed cutting off the hair and remov-
ing part of the skin of the skull. Scalping implied permanent visual
mutilation. Given the persistence of beliefs in the magical value of
hair, decalvatio in the Longobard culture was a dishonorable punish-
ment. Two reasons are given for decalvatio: (i) soldiers who left the
field of battle with a loss of manhood (Venchiarutti, 2006); and (ii) the
iudices (i.e., with public functions) who traded with the Byzantines
without the king's license (Bertolini, 1962). As Gresky et al. (2017)
pointed out, cases of scalping in the osteological record show a
unique pattern of cut marks on the skull. These form a rough circle
around the skull and are clustered in small groups on the frontal, pari-
etal, and occipital bones (Bueschgen & Case, 1996; Toyne, 2011).
None of these cut marks is present on the skull. Moreover, the sex
and the historical background of CT1953 firmly exclude the
decalvatio.
5 | CONCLUSIONS
We employed CT scan and SEM analysis as part of a bioarchaeolo-
gical and paleopathological investigation assessing an Early
MICARELLI ET AL. 7
Medieval Longobard woman's skull. We found that she had sur-
vived several surgeries and experienced long-term trepanation ther-
apy. The last surgery appears to have occurred just before the
individual's death. There is no evidence of trauma, tumor, congeni-
tal disorder, or other pathology; hence, why a Medieval medical
practitioner would undertake such a dangerous surgery is consid-
ered here. Although it is intriguing to consider the possibilities of
ritual or judicial resolution, no biological or historical evidence sup-
ports these hypotheses.
Nevertheless, this represents one of the few pieces of archeologi-
cal evidence of a trepanation surgery performed on Early Medieval
women paving the path for future research on the rationale behind
this dangerous surgical procedure in this period.
ACKNOWLEDGEMENTS
We thank Dr Rossella Bedini of the Istituto Superiore di Sanità in
Rome (IT) for acquiring the CT scans of the skull. We thank Dr Tania
Ruspandini of the Department of Scienze della Terra, Sapienza, Uni-
versity of Rome (IT) and Dr Marco Albano at CNR in Rome (IT) for
SEM acquisitions.
We wish to thank the two anonymous reviewers and the Editor
for their valuable comments and suggestions.
Source of support: “Population biology, diseases and mobility:
Romans and Longobards in the post-classical era”, Grande Progetto
Sapienza 2018, RG118164364E4CB5; HORIZON EUROPE Marie
Sklodowska-Curie Actions, B-CARED Osteobiographical investigation
of disability and care in Medieval Europe, 101061838.
This study does not involve any modern human or animal subject.
Open Access Funding provided by Universita degli Studi di Roma La
Sapienza within the CRUI-CARE Agreement.
CONFLICT INTEREST STATEMENT
The authors declare no conflicts of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Ileana Micarelli https://orcid.org/0000-0001-7498-5218
Flavia Strani https://orcid.org/0000-0003-4566-3644
Samuel Bedecarrats https://orcid.org/0000-0001-6016-577X
Sara Bernardini https://orcid.org/0000-0001-7283-6323
Valentina Gazzaniga https://orcid.org/0000-0003-2110-4856
Mary Anne Tafuri https://orcid.org/0000-0002-2913-7225
Giorgio Manzi https://orcid.org/0000-0002-8611-1371
REFERENCES
Aidonis, A., Papavramidou, N., Moraitis, K., & Papageorgopoulou, C.
(2021). Trepanations in the ancient Greek colony of Akanthos: Skull
surgery in the light of Hippocratic medicine. International Journal of
Paleopathology, 35, 8–21. https://doi.org/10.1016/j.ijpp.2021.07.008
Barbian, L. T., & Sledzik, P. S. (2008). Healing following cranial trauma.
Journal of Forensic Sciences, 53(2), 263–268. https://doi.org/10.1111/
j.1556-4029.2007.00651.x
Bereczki, Z., Molnár, E., Marcsik, A., & Pálfi, G. (2015). Rare types of trephi-
nation from Hungary shed new light on possible cross-cultural connec-
tions in the Carpathian Basin. International Journal of Osteoarchaeology,
25(3), 322–333. https://doi.org/10.1002/oa.2304
Bertolini, O. (1962). Astolfo, re dei Longobardi. In A. M. Ghisalberti (Ed.).
Treccani, Dizionario Biografico degli Italiani - Volume 4. Istituto Della
Enciclopedia Italiana. online version: https://www.treccani.it/
enciclopedia/re-dei-longobardi-astolfo_%28Dizionario-Biografico
%29/
Bliquez, L. (2014). The tools of Asclepius: Surgical instruments in Greek and
Roman times (pp. 185–195). Brill.
Bueschgen, W. D., & Case, D. T. (1996). Evidence of prehistoric scalping at
Vosberg, Central Arizona. International Journal of Osteoarchaeology,
6(3), 230–248. https://doi.org/10.1002/(SICI)1099-1212(199606)6:
3<230::AID-OA268>3.0.CO;2-Y
Buikstra, J. E., & Ubelaker, D. H. (1994). Standard for data collection from
human skeletal remains, Arkansas archaeological survey research series,
n. 40. Wiley.
Camar
os, E., Sánchez-Hernández, C., & Rivals, F. (2016). Make it clear:
Molds, transparent casts and lightning techniques for stereomicro-
scopic analysis of taphonomic modifications on bone surfaces. Journal
of Anthropological Sciences, 94, 1–8.
Cvetkovi
c, D., Jadzˇi
c, J., Milovanovi
c, P., Djoni
c, D., Djuri
c, M.,
Bracanovi
c, D., Nikoli
c, S., & Zˇivkovi
c, V. (2020). Micro-computed
tomography study of frontal bones in males and females with hyperos-
tosis frontalis interna. Calcified Tissue International, 107, 345–352.
https://doi.org/10.1007/s00223-020-00730-2
Delogu, P. (2016). Storia immaginaria dei Longobardi di Castel Trosino. In
A. Chavarrìa Arnau & M. Jurkovicì (Eds.). Alla Ricerca di un Passato
Complesso. Contributi in onore di Gian Pietro Brogiolo per il suo settante-
simo compleanno (pp. 83–100). Brepols Publishers.
Ebanista, C., & Rotili, M. (2010). Ipsam Nolam barbari vastaverunt. L'Italia e
il mediterraneo occidentale tra il V secolo e la metà del VI. Atti del
convegno internazionale di studi. Cimitile-Nola-Santa Maria Capua
Vetere, 18–19 giugno 2009 (Vol. 2).
Eks¸i, M. Ş., Güdük, M., & Usseli, M. I. (2021). Frontal bone is thicker in
women and frontal sinus is larger in men: A morphometric analysis.
The Journal of Craniofacial Surgery, 32(5), 1683–1684. https://doi.org/
10.1097/SCS.0000000000007256
Gasparri, S., & Azzara, C. (2011). Le leggi dei longobardi: storia, memoria e
diritto di un popolo germanico. In S. Gasparri & C. Azzara (Eds.). Le
leggi dei Longobardi (pp. 1–473). Viella.
Gazzaniga, V., & Marinozzi, S. (2015). Strumenti per la trapanazione del
cranio: una storia di ‘lunga durata’. Giornale Italiano di Ortopedia e
Traumatologia, 41, 246–251.
Gomez, C. K., Schiffman, S. R., & Bhatt, A. A. (2018). Radiological review of
skull lesions. Insights into Imaging, 9(5), 857–882. https://doi.org/10.
1007/s13244-018-0643-0
González-Darder, J. M. (2019). Cranial Trepanation During the Middle
Ages. In J. M. González-Darder (Ed.). Trepanation, trephining and
craniotomy (pp. 95–107). Springer. https://doi.org/10.1007/978-3-
030-22212-3
Gresky, J., Batieva, E., Kitova, A., Kalmykov, A., Belinskiy, A.,
Reinhold, S., & Berezina, N. (2016). New cases of trepanations from
the 5th to 3rd millennia BC in southern Russia in the context of previ-
ous research: Possible evidence for a ritually motivated tradition of
cranial surgery? American Journal of Physical Anthropology, 160(4),
665–682. https://doi.org/10.1002/ajpa.22996
Gresky, J., Haelm, J., & Clare, L. (2017). Modified human crania from
Göbekli Tepe provide evidence for a new form of Neolithic skull cult.
Science Advances, 3(6), e1700564. https://doi.org/10.1126/sciadv.
1700564
8 MICARELLI ET AL.
Hershkovitz, I., Greenwald, C., Rothschild, B. M., Latimer, B., Dutour, O.,
Jellema, L. M., & Wish-Baratz, S. (1999). Hyperostosis frontalis interna:
An anthropological perspective. American Journal of Physical Anthropol-
ogy, 109(3), 303–325. https://doi.org/10.1002/(SICI)1096-8644
(199907)109:3<303::AID-AJPA3>3.0.CO;2-I
Jørgensen, L. (1991). Castel Trosino and Nocera umbra. A chronological
and social analysis of family burial practices in Lombard Italy (6th–8th
cent. AD). Acta Archaeologica, 62, 1–58.
Király, K., Váradi, O. A., Kis, L., Nagy, R., Elekes, G., Bukva, M., Tihanyi, B.,
Spekker, O., Marcsik, A., Molnár, E., Pálfi, G., & Bereczki, Z.
(2022). New insights in the investigation of trepanations from
the Carpathian Basin. Archaeological and Anthropological Sciences,
14(4), 1–17.
Kranioti, E. F. (2015). Forensic investigation of cranial injuries due to blunt
force trauma: Current best practice. Research and Reports in Forensic
Medical Science, 5, 25.
Larsen, C. S. (2015). Bioarchaeology: Interpreting behaviour from the human
skeleton (Vol. 69). Cambridge University Press.
Lisowski, F. P. (1967). Prehistoric and early historic trepanation. In D. R.
Brothwell & A. T. Sandison (Eds.). Diseases in antiquity (pp. 651–672).
Ch C Thoma.
Lovell, N. C. (1997). Trauma analysis in paleopathology. American Journal
of Physical Anthropology, 104, 139–170. https://doi.org/10.1002/(
SICI)1096-8644(1997)25+<139::AID-AJPA6>3.0.CO;2-#
Marques, C. (2019). Tumors of bone. In J. Buikstra (Ed.). Ortner's identifica-
tion of pathological conditions in human skeletal remains (pp. 639–717).
Academic Press.
Mednikova, M. B. (2003). Ritual initiation in prehistoric Eurasians based on
cranial data: Symbolic trephinations. Archaeology, Ethnology and
Anthropology of Eurasia, 1(13), 147–157.
Meindl, R. S., & Lovejoy, C. O. (1985). Ectocranial suture closure: A revised
method for the determination of skeletal age at death based on the
lateral-anterior sutures. American Journal of Physical Anthropology, 68,
57–66. https://doi.org/10.1002/ajpa.1330680106
Mengarelli, R. (1902). La necropoli barbarica di Castel Trosino presso Ascoli
Piceno. Roma.
Micarelli, I., Paine, R. R., Tafuri, M. A., & Manzi, G. (2021). Conservation
and reassessment of an overlooked skeletal collection preserved since
1901 at the Museum of Anthropology “G. Sergi”, Rome. Conservation
Science in Cultural Heritage, 20, 65–78. https://doi.org/10.6092/issn.
1973-9494/12788
Nerlich, A. G., Zink, A., Szeimies, U., Hagedorn, H. G., & Rösing, F. W.
(2003). Perforating skull trauma in ancient Egypt and evidence for
early neurosurgical therapy. In R. Arnott, S. Finger, C. Smith, & R.
Arnott (Eds.). Trepanation history, discovery? Theory (pp. 191–202).
Swets & Zeitlinger Publishers.
Perrot, R. (1982). Les blessures et leur traitement au Moyen-Age d'apres
les textes medicaux anciens et les vestiges osseux, grande region
Lyonnaise. Diss. Universite Claude Bernard: Lyon.
Profumo, M. C., & Staffa, A. R. (2007). Le necropoli altomedievali ed il sito
fortificato di Castel Trosino. In E. Catani & G. Paci (Eds.). La Salaria in
età tardoantica e altomedievale (Atti del Convegno), Roma (pp. 393–
394). Arbor Sapientiae.
Redfern, R., & Roberts, C. (2019). Chapter 9 – Trauma. In J. Buikstra (Ed.).
Ortner's identification of pathological conditions in human skeletal
remains (pp. 211–284). Academic Press.
Ricci, M., & Paroli, L. (2007). La necropoli altomedievale di Castel Trosino.
All'insegna del Giglio.
Riccomi, G., Bareggi, A., Minozzi, S., Aringhieri, G., Pellegrino, C., &
Giuffra, V. (2022). Paleopathology of Endocranial lesions: A possible
Case of a middle meningeal artery aneurysm in an Etruscan child from
Pontecagnano (southern Italy). World Neurosurgery, 158, 168–173.
https://doi.org/10.1016/j.wneu.2021.11.093
Rubini, M., & Zaio, P. (2011). Warriors from the east. Skeletal evidence of
warfare from a Lombard-Avar cemetery in Central Italy (Campochiaro,
Molise, 6th–8th century AD). Journal of Archaeological Science, 38(7),
1551–1559. https://doi.org/10.1016/j.jas.2011.02.020
Schindelin, J., Arganda-Carreras, I., Frise, E., Kaynig, V., Longair, M.,
Pietzsch, T., Preibisch, S., Rueden, C., Saalfeld, S., Schmid, B.,
Tinevez, J. Y., White, D. J., Hartenstein, V., Eliceiri, K., Tomancak, P., &
Cardona, A. (2012). Fiji: An open-source platform for biological-image
analysis. Nature Methods, 9, 676–682. https://doi.org/10.1038/
nmeth.2019
Sergi, S. (1902). Appendice, Nota sui teschi di Castel Trosino. In R. Men-
garelli (Ed.). La necropoli barbarica di Castel Trosino presso Ascoli Piceno
(pp. 189–192). Accademia dei Lincei.
Strani, F., Profico, A., Manzi, G., Pushkina, D., Raia, P., Sardella, R., &
DeMiguel, D. (2018). MicroWeaR: A new R package for dental micro-
wear analysis. Ecology and Evolution, 8, 7022–7030. https://doi.org/
10.1002/ece3.4222
Toyne, J. M. (2011). Possible cases of scalping from pre-Hispanic highland
Peru. International Journal of Osteoarchaeology, 21(2), 229–242.
https://doi.org/10.1002/oa.1127
Venchiarutti, W. (2006). Longobardi e Longobardismi, Spunti e suggestioni
antropologiche nelle consuetudini del Cremasco, Insula Fulcheria
XXXVI, Comune di Crema. https://www.comunecrema.it/insula-
fulcheria/insula-fulcheria-indice-completo/insula-fulcheria-rivista-n-
xxxvi-2006
Verano, J. W. (2017). Reprint of-differential diagnosis: Trepanation. Inter-
national Journal of Paleopathology, 19, 111–118. https://doi.org/10.
1016/j.ijpp.2017.03.004
Walker, P. L., Dean, G., & Shapiro, P. (1991). Estimating age from tooth
wear in archaeological populations. In M. A. Kelley & C. S. Larsen
(Eds.). Advances in dental anthropology (pp. 169–178). Wiley-Liss.
Ye, Y., Gao, W., Xu, W., Gong, J., Qiu, M., Long, L., & Ding, J. (2022). Ana-
tomical study of arachnoid granulation in superior sagittal sinus corre-
lated to growth patterns of Meningiomas. Frontiers in Oncology, 12,
848851. https://doi.org/10.3389/fonc.2022.848851
How to cite this article:Micarelli, I., Strani, F., Bedecarrats, S.,
Bernardini, S., Paine, R. R., Bliquez, L., Giostra, C., Gazzaniga,
V., Tafuri, M. A., & Manzi, G. (2023). An unprecedented case
of cranial surgery in Longobard Italy (6th–8th century) using a
cruciform incision. International Journal of Osteoarchaeology,
1–9. https://doi.org/10.1002/oa.3202
MICARELLI ET AL. 9