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1 Both authors: Department of Radiology, Emory University Hospital, 1364 Clifton Rd., N.E., Atlanta, GA 30322.
Received November 7, 2001;
accepted after revision December 20, 2001.
Presented at the annual meeting of the American Society of Neuroradiology,
Boston, April 2001.
Abstract
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MATERIALS AND METHODS. Nine Egyptian mummies were evaluated on helical CT using 1-mm axial scans obtained from the skull vertex to the mid cervical spine. Systematic evaluation of the skull and intracranial contents, paranasal sinuses, craniocervical junction, orbits, temporal bones including the middle and inner ears, teeth, and superficial soft tissues was undertaken. Reformatted and volume-rendered images were generated.
RESULTS. CT findings indicated that the intracranial contents of the nine mummies varied tremendously. Destruction of the anterior skull base structures in mummies without intracranial contents suggested a transnasal, transethmoidal approach to excerebration. A large amount of expensive embalming material within the skull of one mummy suggests that he may have been a royal pharaoh. A cleft palate deformity was identified in a child mummy. Temporal bone analysis revealed one case of asymmetric mastoid air cell erosion and dehiscence, which is strongly suggestive of prior mastoiditis. Craniocervical junction abnormalities and ossicular chain disruption in several mummies were attributed to postmortem damage. The orbital structures had intentionally been removed in several mummies. Dental disease was ubiquitous among the adult specimens.
CONCLUSION. The systematic evaluation of the head and skull base of mummies with CT can provide insight into the life, disease, death, and postmortem treatment of these ancient Egyptians.
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CT has become the primary means of studying these embalmed individuals because of its ability to noninvasively, thus nondestructively, reveal both internal and superficial structures while providing excellent spatial and contrast resolution. Current post-processing algorithms enable the manipulation of CT data so that images can be generated in multiple planes and in three-dimensional formats, further expanding the abilities and uses of CT. Our goal was to perform a comprehensive, systematic review of multiple components of the face, head, and skull base of nine Egyptian mummies using thin-collimation CT imaging and advanced reconstruction techniques.
We reviewed the integrity and appearance of the skull and intracranial contents, craniocervical junction, skull base, paranasal sinuses, temporal bones, middle and inner ears, orbits, dentition, and superficial soft tissues. To our knowledge, a broad yet systematic evaluation of these structures in a collection of mummies this size has not heretofore been published in the radiology literature. In this investigation, we hoped to show that advanced CT can provide substantial information about the anatomy, pathology, and postmortem treatment of these ancient Egyptians.
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All mummies were evaluated on a helical CT scanner (General Electric Medical Systems, Milwaukee, WI) with 1-mm axial images from the skull vertex through the mid cervical spine. The scanning parameters were 70-100 mA/sec, 120-140 kVp, and a pitch of 1.0; no gantry tilt was used. The number of axial images generated per mummy ranged from 126 to 218.
Each set of images was systematically evaluated in the axial, coronal, and sagittal planes for integrity of the skull and skull base (anterior, central, and posterior); the presence or absence of intracranial contents; the morphology of the paranasal sinuses; and the appearance and condition of the craniocervical junction, dentition, orbits, temporal bones, middle and inner ears, and soft tissues of the face. Detailed multiplanar and two- and three-dimensional volume-rendered images of the head and face were methodically generated on-site at a workstation (Advantage Windows [version 3.1]; General Electric Medical Systems).
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Because the brain held no particular value to the Egyptians and was a potential source of putrefaction after death, the brain was traditionally removed from a corpse before embalming and burial [9,10,11,12]. Historical accounts by Herodotus describe the insertion of a curved metal hook into the nostril of a corpse and the removal of the cranial contents via a transnasal, transethmoidal approach [11]. Four of the mummies in our study had skull base abnormalities reflecting this means of excerebration. In these four specimens, the ethmoidal sinuses were either partially or completely destroyed (Fig. 1A,1B,1C). The side of traumatic penetration was variable: right-sided destruction in two mummies from the 19th Dynasty, left-sided destruction in a child from the 25th or 26th Dynasty, and bilateral destruction of the ethmoidal sinuses in the other child from the same era. Although the defects were evident on CT scans obtained in the traditional axial plane, sagittal and coronal reformations were illustrative in further showing the location and extent of the bony abnormalities. Using volume-rendering algorithms, we generated three-dimensional images that provided additional perspectives of these defects.
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Axial CT of the skull of the child with the calvarial fracture showed a bony fragment that had been displaced into the posterior aspect of the skull (Fig. 2A). The morphology of this fragment was difficult to conceptualize on images obtained in the axial plane; this finding was more easily identifiable as a piece of sphenoid bone on three-dimensional reformations (Fig. 2B). Although invasion and destruction of the ethmoidal sinuses were apparent, the brain appears to have been removed more aggressively in this child than in the other mummies via a posteriorly oriented, transsphenoidal approach.
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Intracranial Contents
The brain was absent from the four mummies with traumatic anterior skull
base defects. Although the cranial vault was primarily empty in three of these
mummies, approximately half of the cranium of mummy 4 was filled with a large
amount of resin, an embalming fluid (Fig.
3). Two different densities within this hardened molten mass are
clearly depicted, suggesting either that the fluid was poured in two different
installments or that it had layered into sediments before hardening into a
solid mass. A small amount of resin was identified in only one other mummy:
one of the children from the 25th or 26th Dynasty.
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The brain was left in situ in the remaining five mummies, a finding that contradicted traditional accounts of mummification. Although varying in appearance, the brain typically atrophied and settled in the dependent (posterior) portion of the skull (Figs. 4,5,6). Residual dural linings were also evident in three of the five mummies, thus confirming that no attempt was made to remove the brain.
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Craniocervical Junction
The craniocervical junction was abnormal in three of the nine mummies
studied. The abnormalities included rotary subluxation and dislocation
(Fig. 7). Although the cases
of rotary subluxation were evident on images obtained in the traditional axial
plane, craniocervical dislocation was best illustrated on the reformatted
coronal images.
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Temporal Bone and Middle and Inner Ears
The external auditory canals were normal in all nine mummies. Remarkably,
despite up to 3000 years of elapsed time, the fragile middle ear ossicles were
pristinely preserved bilaterally in three of the mummies
(Fig. 8). The ossicular chain
was disrupted in six of the nine of the mummies studied. Abnormalities ranged
from ossicular subluxation and dislocation to the complete absence of all
ossicles. The inner ear, including the otic capsule and cochlea, vestibule,
and semicircular canals, was normal in all the specimens.
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Mastoid air cells in eight of the nine mummies were well pneumatized and normal in architecture bilaterally. Asymmetric sclerosis, erosion, and dehiscence of the lateral right mastoid air cells and sigmoid plate in one of the adult male mummies were seen (Fig. 9A), in addition to discontinuity of the adjacent cortical bone at the occipitomastoid confluence.
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Dentition
Extraction sockets, fractured teeth, and periapical radiolucencies were
identified in all seven adult mummies to various degrees. Dental caries was
suggested in only two of the adult mummies. Mild to moderate erosion of the
cusps of the molars and premolars was seen in two of the adult male mummies.
These abnormalities were difficult to appreciate on the axial images but were
readily apparent on images obtained in the sagittal plane and on the
three-dimensional reformations (Fig.
10A,10B).
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The two pediatric specimens had unerupted teeth, the pattern of which helped establish the approximate ages at the time of death as 2 and 5 years.
A thin, corticated bony defect was revealed in the paramedian hard palate of one of the child mummies. The defect primarily involved the anterior midline alveolar process of the maxilla and did not appear to extend into the posterior palate. Evident on contiguous axial images and those reproduced in a three-dimensional format, this abnormality is believed to represent a mild form of a cleft palate (Fig. 11A,11B). Volume-rendered shaded-surface—display images suggested that this child also may have had a cleft lip.
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Orbital Structures
The atrophied remains of the extraocular muscles and optic nerves were
identifiable in six of the nine mummies
(Fig. 12). The definitive
identification of the globe was more variable, and the lenses were distinctly
seen in only one mummy (Fig.
13).
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In one male mummy, the right orbital structures were absent, and fractures of the adjacent lamina papyracea were detected. These findings suggest that the removal of the orbital contents was intentional. In two other mummies, the orbital structures were also absent and embalming debris was present in the empty bony orbits.
Facial Soft Tissues
Study of superficial soft-tissue features with both standard and
three-dimensional imaging methods revealed complete or partial destruction of
the bony and cartilaginous structures of the nose in four mummies. In three of
these mummies, this damage was likely related to traumatic transnasal removal
of the intracranial contents. A wad of resin-soaked linen was placed over the
left side of a child's nose after the cartilaginous structures had been
destroyed (Fig. 14). The
three-dimensional reconstruction of one mummy showed a deformity of the nose
(Fig. 15); this finding
reflects the underlying nasal and maxillary sinus fractures depicted on the
axial images. This image also nicely shows that the orbits in this woman are
sunken, apparently having been removed.
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Three-dimensional reconstructions of another mummy also revealed a deformity of the pinna of the right ear (Fig. 16), a detail that was difficult to appreciate on images obtained in the standard axial plane.
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Volume-rendered images were remarkably similar to the true appearance of the mummies.
Other Findings and Normal Variants
Careful study of the head and skull base features of the nine mummies
resulted in the detection of normal variants and other incidental findings.
Linen packing was identified in the oropharynx or hypopharynx of three mummies
(Fig. 5). This material was
probably strategically placed to restore the lifelike contours to the face and
soft tissues of the neck. A small resin-coated pledget was present in the
right nostril of one of the child mummies
(Fig. 11A).
Other normal variants included a large pneumatized frontal sinus, concha bullosa, several cases of nasal septal deviation, and one highriding jugular bulb.
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A finding of particular interest was the presence of a large amount of resin within the skull of one of the adult male mummies. Resin was an expensive aromatic embalming fluid derived from trees that was used in the mummification process during several dynasties. The contrast resolution inherent to CT enabled the identification and characterization of two different densities of the embalming fluid, a detail that was not evident on the radiographs of the skull. This finding suggests that the resin either was poured into the cranium in two different installments or, alternatively, was composed of different sediments that precipitated before drying into a molten mass. A growing body of evidence in the Egyptology literature and radiology literature supports the hypothesis that this particular male mummy lived during the 19th Dynasty of the New Kingdom and is of royal lineage, perhaps the lost body of Ramesses I, the first ruler of the 19th Dynasty. The large amount of expensive embalming fluid found in the skull and elsewhere in the body of this individual corresponds with known New Kingdom mummification techniques and further supports this theory.
In four of five mummies from the 21st Dynasty, the brain was left intact. Although this practice may indicate that the deceased were of a lower social status, this trend suggests that mummification techniques were simplified during this time period, because evidence of brain removal has more typically been found in mummies from earlier periods.
Egyptologists and the general population alike are interested in the afflictions and possible causes of death of these ancient people. Although speculative, our findings identify a potential contributor to or cause of death in two of the nine mummies studied. A complex, partially depressed skull fracture in a child mummy raises the possibility of a traumatic antemortem head injury. The absence of callous formation, indicating there was not enough time for bone healing to occur, suggests the relative acuity of the trauma. The location and appearance of this skull fracture are not likely to have been related to brain removal, because brain removal is accounted for by traditional skull base and sinus fractures. Furthermore, it is less likely that this fracture resulted from postmortem mishandling because only one other fracture (of the distal femur) was identified in this specimen, whereas mummies that are indiscriminately handled typically have innumerable fractures throughout the entire bony skeleton. These fractures usually reflected previous attempts by vandals to steal or unwrap mummies in the hopes of finding jewels, which were often wrapped beneath the linens. This same child had a piece of the sphenoid bone displaced into the posterior skull. Three-dimensional reformations of this bony piece were helpful in establishing its shape and identity.
The other, and potentially more noteworthy, finding that may be related to morbidity, if not mortality, was the discovery of evidence of mastoid disease in the potential male pharaoh. The asymmetric sclerosis, erosion, and dehiscence of the mastoid air cells in this adult male strongly suggest prior inflammatory mastoid disease—that is, mastoiditis. This condition has been previously described, most notably by Brothwell and Sandison [18] who in 1967 reported seven cases of mastoiditis in Egyptian remains. The apparent bony destruction in the mummy in our collection suggests a process that was chronic and recurrent. The reason for Ramesses I's brief 2-year reign and presumed hasty demise is a mystery. If this mummy is in fact the royal pharaoh, one might speculate that almost 3000 years ago an episode of acute untreated mastoiditis could potentially be a source of intracranial or widespread infection and subsequent death. Of additional interest is the discontinuity of the cortical bone posterior to the mastoid abnormality at the occipitomastoid confluence; this finding raises the possibility that interventional efforts were attempted to facilitate healing of the condition.
Examination of the temporal bone and middle ear revealed either disruption or the absence of the ossicular chain in six mummies. Similar findings were reported by Yardley and Rutka [4] using CT scans and direct otoscopic examinations. Given the absence of associated temporal bone abnormalities in all but one of these mummies (the one with possible mastoiditis), we have also concluded that these fragile ossicles were disrupted in the postmortem state and are not indicative of antemortem pathology.
To our knowledge, the craniocervical junction of mummies has not been studied. Evidence of either dislocation or rotary subluxation of the craniocervical junction in three mummies was found. Because these mummies also had innumerable other fractures, these abnormalities are also thought to reflect postmortem mishandling. Although rotary subluxation of the craniocervical junction was evident on standard axial images, reformatted images in the coronal plane better showed dislocation of the craniocervical junction.
The utility of advanced CT imaging and postprocessing techniques was further highlighted by the application of volume-rendering algorithms in the evaluation of soft tissues. Contour abnormalities of the face that were difficult to appreciate on images obtained in the axial plane were readily apparent on three-dimensional images.
Several authors have dedicated book chapters and journal articles solely to the study of ancient Egyptian teeth [2, 3, 5, 19]. The mummies in our collection, like those studied before them, overwhelmingly suffered from varying degrees of dental and periodontal disease. Ancient Egyptians suffered greatly from antemortem tooth loss [19], as evidenced in our study by a large number of empty sockets. These findings may have resulted partly from periodontal disease, which was also present in most of the adult mummies in this study. Evidence of generalized tooth cusp attrition was present in two mummies. Apparently widespread in ancient Egypt, tooth cusp attrition has been attributed to the large amount of coarse, erosive grit and sand in the diet of most Egyptians. The easy identification of these abnormalities on sagittal and three-dimensional images again highlights the importance and utility of multiplanar, multidimensional CT.
Evaluation of the teeth revealed the presence of a mild form of cleft palate in one of the child mummies. To the best of our knowledge, this abnormality has rarely been reported in the Egyptology literature. Although the defect is confined to the alveolar ridge and is seemingly mild, this child may have experienced eating and speech difficulties and an increased predisposition to infection.
The orbital structures were primarily intact, albeit atrophied, in six of the mummies in this collection. The meningeal sheath of the optic nerve could be identified to varying degrees, as could the atrophied extraocular muscles and their fascial sheaths. The unilateral absence of orbital structures in one mummy, who also had ipsilateral lamina papyracea fractures, strongly suggested intentional and traumatic removal of the orbital contents. Only three of the five mummies thought to be from the same dynasty had intact orbital structures; this finding suggests that mummification techniques varied during the same era, possibly reflecting the different social or financial status of the decreased. The globes were difficult to identify, and the lenses were distinctly identified in only one well-preserved male mummy, which suggests that these structures were probably vulnerable to the harsh effects of the embalming process.
Our CT findings indicate that despite a difference of 3000 years and different cultures the general anatomy and morphology of the skull and skull base have not changed significantly over the last 3000 years. Normal variants seen on present-day head CT scans—including large pneumatized sinuses, concha bullosa, deviation of the nasal septum, or a high-riding jugular bulb—were all seen among this collection of ancient people.
In conclusion, CT is a highly effective, nondestructive method of studying the head and skull base of Egyptian mummies. Exquisite anatomic details can be revealed while leaving the specimen intact. A standard thincollimation helical technique produced images of good resolution and quality. These images can be further manipulated and reviewed in coronal, sagittal, and three-dimensional formats to generate images in the most informative and illustrative plane for viewing. Using these imaging techniques for the methodic evaluation of the skull and skull base of nine Egyptian mummies yielded information of historical, paleopathologic, and general interest, including evidence of congenital defects, antemortem disease, causes of death, and generalized variance in mummification techniques. This study affirms that radiology—in this case, advanced CT imaging and postprocessing techniques—is an indispensable tool in the multidisciplinary investigation of Egyptian mummies.
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