A Plausible Historical and Forensic Account of the Death of Thomas Aquinas

Abstract

Thomas Aquinas (1225–1274) was an influential medieval Christian theologian and arguably one of the greatest scholastic philosophers. He produced more than 60 works in his 48 years, including his magnum opus, the Summa Theologica. The Catholic Church regards him as a canonized saint and one of 37 Doctors of the Church. On his way to an ecumenical council in 1274, he was “struck with sudden illness” requiring rest at a monastery where he was cared for until death several weeks later. An obscure Latin text describes an incident where he hit his head violently on an overhanging branch. Becoming progressively ill, he arrived at a Cistercian abbey where he died on March 7. Through an analysis of his final illness as documented in key Latin and Italian historical texts, and careful observation of the reputed skull relic in Priverno, Italy, the authors postulate that Aquinas may have suffered a traumatic brain injury and that his death at age 48 was occasioned by a chronic subdural hematoma. Examination of the skull was inconclusive; however, the historical textual analysis supports this theory. A more in-depth forensic analysis of the skull may help confirm the diagnosis.

Full text

A Plausible Historical and Forensic Account of the Death of Thomas Aquinas
Gabriel J. LeBeau
1,2
, Abdul-Rahman Alkiswani
1
, Daniel J. Mauro
3
, Paul J. Camarata
2
INTRODUCTION
The year 2023 marks the 700
th
anniversary
of the canonization of one of the most
influential saints of the Catholic Church,
Thomas Aquinas. Born in southern Italy in
1225, Aquinas is one of the 37 Doctors of
the Catholic Church, a title that empha-
sizes an individual’s impact on the doc-
trine and teaching of the Church. Widely
considered one of the greatest thinkers in
the Western Canon, the work of Aquinas
has influenced generations in their pursuit
of truth, regardless of faith or creed.
Despite living only to the age of 48, he still
managed to amass over 10,000,000 words
in some 60 works of philosophy and the-
ology.
1
His prolific writing and nearly
illegible handwriting caused a 13-century
source to aver that he “used to dictate in
his cell to 3 secretaries, and even occa-
sionally to 4, on different subjects at the
same time,”
1
with nearly illegible
handwriting (Figure 1).
2
The brilliance
needed to maintain this intense level of
production and scholastic clarity remains
unmatched.
Aquinas’most famous work is the
Summa Theologica, arguably one of the
greatest works of philosophy and theology
ever written. He also wrote many com-
mentaries on the works of Aristotle, syn-
thesizing the ancient classical thought of
this pagan philosopher with the medieval
scholastic methods of theology, philoso-
phy, and discourse (Figure 2, portraits of
Aquinas).
3,4
At the time, the emphasis on the
thought of pagan philosophers such as
Aristotle was highly controversial within
the Catholic Church. Aquinas greatly
championed the synthesis of faith and
reason, a concept that continues to influ-
ence modern epistemology, including
within the context of the modern scientific
method.
No commemoration of Aquinas’life can
exclude consideration of its end. Contro-
versy surrounds the true nature of his
death, with theories ranging from a
nondescript sudden illness to an assassi-
nation with poison by the king of Naples.
5
Recent scholarship has pointed out the
potential neurological nature of his death
from a stroke or an epidural hematoma.
6
On his journey to Lyon, France in 1274,
one biographical account describes an
otherwise-healthy Aquinas sustaining a
traumatic injury to the head that seemed
to mark the beginning of his demise.
From the symptoms, timeline, and nature
of his injury, we postulate that Aquinas
died of a growing chronic subdural he-
matoma secondary to a head injury sus-
tained several weeks before his death.
METHODS AND SOURCES
To examine the events concerning his
death, the authors studied a combination
of primarily 13
th
and 14
th
-century Latin
documents and more recent secondary
sources in Italian and Latin. Obscure Latin
texts in these primary sources were
translated into English by a member of the
research team (DJM). These documents
included primary biographical records
from witnesses and historians named
Petro Calo, William de Tocco, and Bar-
tholomaeus de Capua, written within a
few years to a few decades after Aquinas’
death. Transcripts from witness testimony
for the cause of his canonization were also
translated. Secondary sources included
books written by 20
th
-century Dominican
friars James A. Weisheipl and Jean-Pierre
Torrell.
7,8
Many 13
th
and 14
th
century
primary Latin document sources were
sourced from a single collection.
9
(Figure 3)
Thomas Aquinas (1225e1274) was an influential medieval Christian theologian
and arguably one of the greatest scholastic philosophers. He produced more
than 60 works in his 48 years, including his magnum opus, the Summa Theo-
logica. The Catholic Church regards him as a canonized saint and one of 37
Doctors of the Church. On his way to an ecumenical council in 1274, he was
“struck with sudden illness”requiring rest at a monastery where he was cared
for until death several weeks later. An obscure Latin text describes an incident
where he hit his head violently on an overhanging branch. Becoming progres-
sively ill, he arrived at a Cistercian abbey where he died on March 7. Through an
analysis of his final illness as documented in key Latin and Italian historical
texts, and careful observation of the reputed skull relic in Priverno, Italy, the
authors postulate that Aquinas may have suffered a traumatic brain injury and
that his death at age 48 was occasioned by a chronic subdural hematoma. Ex-
amination of the skull was inconclusive; however, the historical textual analysis
supports this theory. A more in-depth forensic analysis of the skull may help
confirm the diagnosis.
Key words
-Chronic subdural hematoma
-Historical vignette
-Thomas aquinas
-Traumatic brain injury
Abbreviations and Acronyms
cSDH: chronic subdural hematoma
From the
1
The University of Kansas School of Medicine,
Kansas City, Kansas;
2
Department of Neurological Surgery,
University of Kansas Medical Center, Kansas City, Kansas;
and
3
Kenrick-Glennon Roman Catholic Theological Seminary,
St. Louis, Missouri, USA
To whom correspondence should be addressed:
Paul J. Camarata, M.D.
[E-mail: pcamarata@kumc.edu]
Citation: World Neurosurg. (2024) 182:45-51.
https://doi.org/10.1016/j.wneu.2023.11.041
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
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rights reserved.
WORLD NEUROSURGERY 182: 45-51, FEBRUARY 2024 www.journals.elsevier.com/world-neurosurgery 45
Historical Vignette

To further investigate the circumstances
surrounding Aquinas’death, the authors
visited the Cathedral of Priverno, which
houses the putative relic of Aquinas’skull,
and the Fossanova abbey in which he died,
though extensive renovations have
occurred at the abbey over 700þyears.
The room in which Aquinas died remains
extant. The authors were seeking to eval-
uate the skull for forensic evidence point-
ing towards fractures or other forms of
trauma that could further elucidate the
neurologic nature of his death.
Examination of Skull Relic in Priverno,
Italy
In an attempt to investigate the reputed
skull of Thomas Aquinas for any obvious
sign of trauma, the authors were able to
observe and obtain high-quality pictures of
the skull fragment, now reduced to
essentially only a mask. The mandible and
any calvarium posterior to the frontal bone
were absent. We were not allowed access
to the skull beyond photographs within its
reliquary (Figure 4). Although no
meaningful conclusions to the question
at hand can be made from the
investigation of the skull housed in
Priverno, the authors interviewed the
custodians of the relic and obtained
certain texts in both Italian and Latin for
translation into English.
10,11
Traditional and Current Views of Aquinas’
Death
A variety of theories surround the death of
Aquinas. Some accounts describe a
nondescript sudden general illness while
others claim poisoning.
5
The poisoning
account involves King Charles I of
Naples. As the story goes, King Charles
feared that Aquinas might be appointed
cardinal in Lyon. Because of the king’s
fear that Aquinas would not look
favorably on his governance, accounts
said the King had Aquinas poisoned.
There is no substantial evidence to
support this theory,
7
nor were Aquinas’
terminal symptoms consistent with
poisoning. Nevertheless, Dante Alighieri
memorialized the poisoning theory in The
Divine Comedy:
67 Carlo venne in Italia e, per ammenda,
68 vittima fé di Curradino; e poi.
69 ripinse al ciel Tommaso, per
ammenda.
12
67 Charles came to Italy; to make
amends.
68 he made of Conradin his victim;
then,
69 sent Thomas off to Heaven, to make
amends.
13
Several scholars in the 20th century
speculated on the neurologic nature of
Figure 1. The historical archive of the nearly illegible handwriting of Thomas Aquinas,
2
Vatican Library Digital Collection.
46 www.SCIENCEDIRECT.com WORLD NEUROSURGERY,https://doi.org/10.1016/j.wneu.2023.11.041
HISTORICAL VIGNETTE
GABRIEL J. LEBEAU ET AL. THOMAS AQUINAS CHRONIC SUBDURAL

Aquinas’death. On December 6, 1273, the
feast of St. Nicholas, Aquinas had a pro-
found spiritual and religious experience
manifested in a vision that he was unable
to describe. He commented to his com-
panion that all that he had written now
seemed meaningless and “like straw”—
from that moment until his death he
ceased to write.
14
This included leaving
unfinished his magnum opus, the Summa
Theologica. One group has postulated that
this experience may have been a
neurovascular event
6
that ultimately
rendered him unable to write due to
agraphia until the day he died.
Furthermore, these authors make the
novel claim Aquinas’injury resulted in an
epidural hematoma in the setting of
multiple ischemic attacks.
6
The time
course of Aquinas’final illness, dying
several weeks after the injury, would seem
to make that diagnosis highly unlikely as
those with acute epidural hematoma
progress neurologically much quicker.
Events Leading up to the Death of Aquinas
In March of the year 1272, Pope Gregory X
convoked the second ecumenical council
of Lyon, which ultimately convened in
Lyon, France starting in May of 1274.
15
Given the doctrinal nature of the council,
the pope invited Aquinas personally due
to his intellectual abilities to argue for
the reunification of the western and
eastern branches of Christianity,
separated since 1054. When the time
came for travel, Aquinas was residing at
the Dominican friary in Naples. On
January 28, 1274, Aquinas and company
began their journey towards Lyon by
foot,
7
taking the “Via Latina”route
towards Rome (Figure 5).
16
Aquinastookthisroutetovisithisniece
in Maenza. While on the road to Maenza,
one of the canonization witnesses remarks
that Aquinas violently hit his head on a tree
fallen sideways, stunning him, “fere stupe-
factus,”
9
and that he nearly fell to the
ground.
“descendens de civitate Theani per
viam Burgi Novi percussit caput in
quadam arbore que ceciderat per
transversum ita quod fere stupe-
factus quodammodo”.
9
“going down from the city of Teano
along the way of Borgonuovo, he hit
his head on a certain tree which had
fallen sideways, such that he
became stunned and in a certain
way was near falling”.
As can be seen in countless pieces of
art, and confirmed in historical accounts,
Aquinas was a very large, even obese man.
As such, the force of the mechanism of
injury would have been great. Following
the injury, his companion and attendant,
Brother Reginald of Piperno, immediately
ran to meet him. In an attempt to have
Aquinas speak and distract him from the
injury, Brother Reginald mentioned the
rumor that Aquinas would be appointed a
cardinal at the Council. Aquinas dismissed
this discussion but showed that he was
able to speak.
9
The company reached Maenza shortly
after the injury. At this time, Aquinas was
uncomfortable, but there are no accounts
of any severe symptoms. They stayed for
4e5 days in Maenza and Aquinas became
“greatly burdened with infirmity.”
9
Due to
his worsening symptoms, Aquinas
requested a journey to the nearby Abbey
of Fossanova where Cistercian monks in
residence there could care for him.
“Item dixit dictus testis quod
quando idem frater. Thomas incepit
gravari infirmitate, in eodem castro
Magentie, petiit cum multa devo-
tione quod portaretur ad mon-
asterium sancte Marie de Fossa-
Nova, sicque factum est.”
9
“Likewise, the said witness said that
when the same brother Thomas
began to be greatly burdened with
infirmity, in the same field of
Magentia, he asked with great
devotion that he might be carried to
the Monastery of Holy Mary of
Fossanova, and thus it was done.”
His symptoms in Maenza included
nausea, anorexia, and generalized weak-
ness. When the decision was made to
make the half-day journey to the Abbey of
Fossanova, Aquinas was put on the back of
a donkey. Dominicans at the time forbade
members to ride on horseback or donkeys.
That Aquinas rode a donkey indicates his
profound debility and the worsening of his
symptoms.
While at the Abbey of Fossanova, ac-
counts describe worsening generalized
weakness, nausea, and anorexia in the
setting of a lack of focal neurologic defi-
cits, saving one account. This account,
Figure 2. Two representative paintings of Aquinas from Justus van Ghent, left, and Benozzo Gozzoli,
right,Public Domain.
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HISTORICAL VIGNETTE
GABRIEL J. LEBEAU ET AL. THOMAS AQUINAS CHRONIC SUBDURAL

from an Italian document procured from
Priverno, Italy describes an event that
might be considered to represent a
dysphasia.
10
The source outlines an event
where Aquinas ceases to make sense in
the middle of a metaphysical debate.
Brother Reginald, one of Aquinas’many
scribes, states that during this event he
“no longer knew what to write down, as
the master eluded to matters beyond
understanding.”
10
This was the one
short-lived event in all of the sources
evaluated that alluded to a potential focal
neurological deficit. Days later, Aquinas
gave a sermon during mass.
10
Yet, he
resided in the Abbey for “many days
burdened with infirmity”
9
and in one
account, “he lied ill for about a month.”
9
During the final days of his life, Aquinas
still participated in the Mass with great
passion, maintained relative intellectual
capacity in the form of philosophical
discourse, and dictated a commentary on
the Old Testament Book Song of Songs,
though scholars have never found this
alleged work.
8
Upon his arrival in
Fossanova, Aquinas “was very weak and
almost unable to climb the steps of the
staircase [at the abbey].
10
The afternoon
before his death, “he could not walk
smoothly due to fatigue,”so the praying
of the divine office took place in the crypt.
Taking all of this together, Aquinas’
initial injury preceded a period of lucidity
and normalcy followed by a progressive
worsening of his symptoms until his
ultimate demise. James A. Weisheipl, a
20
th
-century Dominican friar and author,
interestingly brings up the concept that
Aquinas may have suffered from a sub-
dural hematoma. “This blow could have
resulted in a clot on the top of the brain
(subdural hematoma) that grew larger and
larger every day; the fact that it was
ingravescent is clear from the events of the
next few weeks.”
7
Evidence for Chronic Subdural Hematoma
Most chronic subdural hematomas (cSDH)
are preceded by some form of minor to
moderate head injury. In most cases, they
are believed to occur because of traumatic
shearing insult to bridging veins that tra-
verse the subdural space and drain to
dural sinuses,
17
resulting in an initial low-
pressure venous hemorrhage. In more
than 50% of cases, no clear head trauma is
identified.
18
Given that Aquinas was
known to be a very large and obese man,
the blow to the head which knocked him
to the ground would seemingly be more
than sufficient to cause such a
hemorrhage.
Within approximately 2 weeks of an
insult causing a small acute SDH,
19
blood
is often resorbed via the breakdown of
erythrocytes and other cellular
components, and fibroblasts form a thick
outer membrane over the inner dural
surface where collagen synthesis is
induced.
20
Then, a thinner inner
membrane encapsulates the formed clot,
resulting in a cSDH. While some
hematomas are completely resorbed,
others may expand as a result of
recurrent bleeding, membrane secretion,
microhemorrhages, or fluid drawn into
the encapsulated clot to further increase
its size.
21
The course of the cSDH is
dictated by the balance of the
reabsorption of the hematoma and fluid
on the one hand and the recurrent
bleeding on the other.
18
In Aquinas’
case, his symptoms fell within the
timeline described.
Chronic SDHs have a reported inci-
dence of around 1.7 to upwards of 20.6 per
100,000 persons per year
22
and are more
likely in older individuals with cerebral
atrophy.
23
Risk factors for SDH
development include significant cerebral
atrophy, since the expanded space
between the cortical surface and adjacent
dural membranes can place increased
Figure 3. Title page of Latin document containing 13th and 14th century
primary sources.
9
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HISTORICAL VIGNETTE
GABRIEL J. LEBEAU ET AL. THOMAS AQUINAS CHRONIC SUBDURAL

tension on bridging veins, resulting in
possible injury. This can occur in the
setting of advanced age, chronic alcohol
abuse, or prior traumatic injury. Other
risks include the use of antithrombotic
agents with the risk of SDH being
highest in patients taking warfarin.
24
Other, more likely coagulopathies such
as thrombocytopenia or known liver
disease
25,26
are known to predispose
individuals to cSDH. There is no
evidence that Aquinas suffered from any
such condition.
With chronic subdurals, the neurologic
examination is often nonfocal, while the
lesion slowly expands in size over weeks
following the inciting injury. Symptoms
may include progressive headaches,
27,28
light-headedness, cognitive impair-
ment,
29
apathy, depression,
30
language
difficulty,
18
Parkinsonism,
31
gait ataxia,
32
somnolence,
33
or seizures.
27,34
CONCLUSIONS
Although differential neurologic diagnosis
and examination techniques were obvi-
ously not employed in the abbey at the
time of Aquinas, a critical reading of the
accounts of the last weeks of his life
makes a strong case for cSDH, with the
classic clinical history of a relatively minor
head trauma, a period of lucidity, and then
a gradual decline as the hematoma ex-
pands over several weeks. Aquinas was not
ill prior to the head injury, and the violent
collision with the tree on the Via Latina
marked the beginning of his demise.
Other accounts describing vague illness,
poisoning, or some sort of infectious eti-
ology are not consistent with the extant
contemporary accounts. The symptoms
Aquinas suffered were not the same as
well-described infectious etiologies of the
time where individuals were described to
be febrile, have dysentery, or emesis.
35
An
epidural hematoma is ruled out by the
time course, as those who suffer from
this entity worsen much quicker—within
hours, not weeks.
Could a Burr Hole Have Saved the World’s
Greatest Theologian?
Paleontological evidence shows that
trephination has been used for thousands
of years for presumably a variety of rea-
sons.
36,37
Currently, operative
neurosurgical intervention is the
treatment of choice for the definitive
management of a cSDH.
38
There are
multiple surgical techniques the surgeon
can choose from when tasked with
evacuating a subdural hematoma
including small craniotomy, twist drill
Figure 4. Photos of the skull relic in Priverno, Italy, reputed to be the skull of
Aquinas.
Figure 5. The “Via Latina” from Capua in Campania to Rome.
16
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HISTORICAL VIGNETTE
GABRIEL J. LEBEAU ET AL. THOMAS AQUINAS CHRONIC SUBDURAL

craniotomy, burr hole drainage, and only
recently the novel middle meningeal
artery embolization.
39,40
Thomas
Aquinas, where he was alive in an era
where this procedure was routinely
performed, likely could have been saved
by this simple procedure and written
treatises for decades more.
Further Study
It was recently discovered that there are 2
different skulls that lay claim to be that of
Aquinas: one in Priverno, Italy, and one in
Toulouse, France. Aquinas’relics
(including a skull) were transferred from
Fossanova to Toulouse, the headquarters
of the Dominican Order at the time, in
1368.
41
Another skull was discovered
enclosed within a wall of the altar in the
Abbey at Fossanova in 1585 with
notarized documents indicating that it
was the true skull of the theologian.
11
This is the skull that currently resides in
Priverno. A true forensic evaluation of
these skulls may aid in authenticating
each group’s claim that their artifact truly
belongs to Thomas Aquinas.
This analysis is admittedly difficult to
perform retrospectively, particularly given
the extended time frame between the
occurrence of the events leading to his
death and their associated reports, as well
as the dearth of clarity regarding his spe-
cific symptoms. In commemoration of the
bicentennial of Mozart’s death, Drake
sought to reevaluate the circumstances
leading to the former’s death.
42
He
concluded that a chronic subdural
hematoma best aligned with the
purported symptoms that Mozart
experienced, the time frame at which
they progressed, and his ultimate
symptoms close to his passing. In
Mozart’sfinal days evidence of possible
herniation syndrome, including vomiting,
headache, hemiparesis, convulsion,
coma, dysconjugate gaze, and facial
weakness, were apparent. Moreover, an
analysis of the likely candidate for his
skull, retrieved 10 years after his humble
burial, revealed signs of a left-sided tem-
poral fracture that was healing, possibly
with concomitant underlying erosion.
We propose that Thomas Aquinas died
from the effects of a chronic subdural
occasioned by his blow to the head several
weeks before his death. Further planned
study includes a more in-depth analysis of
his alleged skull(s) to evaluate for fractures
and other evidence that will further eluci-
date the characteristics of his neurologic
trauma.
The authors are currently investigating
the possibility of further investigation of
each of these skulls with permission of the
appropriate authorities in whose custody
these relics rest.
ACKNOWLEDGMENTS
The authors would like to thank Father
Gilbert Aranha and Don Giovanni Galli-
nari for their assistance in obtaining ac-
cess to the skull relic and subsequent
observation.
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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.
Received 28 August 2023; accepted 9 November 2023
Citation: World Neurosurg. (2024) 182:45-51.
https://doi.org/10.1016/j.wneu.2023.11.041
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
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