Radiological diagnosis of congenital diaphragmatic hernia in 17th century Korean mummy

Abstract

Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm resulting in pulmonary sequelae that threaten the lives of infants. In computed tomography (CT) images of a 17th century middle-aged male mummy (the Andong mummy), we observed that the abdominal contents had protruded into the right thoracic cavity through the diaphragmatic defect, accompanied by a mediastinal shift to the left. On autopsy, the defect in the right posterolateral aspect of the diaphragm was reconfirmed, as was the herniation of the abdominal organs. The herniated contents included the right lobe of the liver, the pyloric part of the stomach, a part of the greater omentum, and the right colic flexure connecting the superior part of the ascending colon and the right part of the transverse colon. Taking our CT and autopsy results together, this case was diagnosed as the Bochdalek-type CDH. Herein we make the first ever report of a CT-assisted diagnosis of a pre-modern historical case of CDH. Our results show the promising utility of this modality in investigations of mummified human remains archaeologically obtained.

Figure 1. Examination of Andong mummy.

(A) Removal of clothing. (B) and (C) Very well preserved human and cultural remains. (B) is hand; (C) is straw shoes. (D) The mummy examined in this study.

Figure 2. Axial CT images of mummies. Left column (A, C, E, G, I and K): the current Andong case with Congenital Diaphragmatic Hernia (CDH); Right column (B, D, F, H, J and L): Gangneung mummy case without CDH.

(A) and (B) TV3 upper level. Ht, heart; RL, right lung; LL, left lung; asterisk, pericardial sac. (C) and (D) TV3 lower level. RL in (C) showed split pattern (a and b). Ht in (C) exhibited mediastinal shift to the left. (D) The similar structure is not seen at the same CT level of Gangneung mummy. (E) and (F) TV5 level. (E) Liver (Lv) is seen at the same level of heart (Ht). Mediastinal shift to the left side is very severe, comparing with normal CT in (F). (G) and (H) TV7 level. (G) Colon (Co) and Liver (Lv) is seen at the same level of heart (Ht). Mediastinal shift is still remarkable. (H) Colon is not observed. Liver (LV) begins to emerge. (I) and (J) TV 9 level. (I) Mainly intestine (Int) is visible. (J) Large liver (LV) could be seen at the same level of Gangneung mummy. (K) and (L) LV1 level. Intestine or other mummified abdominal organs fills the cavity in both CT images.

Figure 3. Coronal CT images of the current Andong mummy with Congenital Diaphragmatic Hernia.

(A) Herniated liver (Lv) could be seen while diaphragm (Dph) is visible underneath. (B) Herniated organs stretching from abdominal to thoracic cavities could be clearly seen. Ht, heart; LL, lung. (C) and (D) Sagittal CT images of Andong mummy. (C) Diaphragm (Dph) is clearly seen between thoracic and abdominal cavity. (D) Herniated organs could be observed through the diaphragmatic defect (asterisk). AA, ascending aorta; DA, descending aorta; Abd A, abdominal aorta.

Figure 4. Dissection of the mummy.

(A) Thoracic and abdominal cavities exposed. Pe, pericardium; Dph, diaphragm; Om, omentum; Pe, pericardium; LL, Left lung; RL, right lung. (B) Magnified image of right thoracic cavity. Parts of liver (Lv) and colon (Co) could be found within the right thoracic cavity. (C) A part of RL is turned back. Lv and Co are much clearly identified. The defect in diaphragm is indicated by arrow. (D) Lv is protruding into the diaphragmatic surface of RL that is therefore folded into anterior (RLA) and posterior parts (RLP). (E) View from cephalic to rostral. Bochdalek hernia (indicated by arrow) in Dph is observed. Lv protrudes through the hernia defect.

Figure 5. Dissection view from abdomen of the mummy.

(A) Diaphragmatic hernia (indicated by arrows) could be seen in the right side of diaphragm (Dph). Liver (Lv) and Colon (Co) are running thorough the diaphragmatic defect. RLA, anterior part of indented right lung; RLP, posterior part of indented right lung; LL, left lung; Om, omentum; Pe, pericardium. Ligamentum teres hepatis is marked by asterisk. (B) Left part of diaphragm (Dph). View from below. Liver (Lv) is also observed in the subdiaphragmatic area. No defects identified in diaphragm.