ki'ua. Othergenera of helminths which inhabit fish have also been de-scribed, and clearly indicated fishing and fish eating. Withfurther studies of latrine residues and coprolite material, onehopes from earlier and earlier deposits, there is thus a chancethat zoonoses will even provide extra information on diet. Literature cited Beaudclte. F.R.. ed. 1955. Psittacosis. Diagnosis. Epidemiologyami Control. New Brunswick. N.J.: Rutgers University Press.Brothwcll, D.R. 198 1 . The Pleistocene and Holoccnc Archaeologyof the House Mouse and Related Species. In R.J. Berry, ed..Biology of Hou.'ie Mouse. 1-1.^. London: Academic Press.Cockshott. P. 1961. Mycetoma. In H. Middlemiss, ed.. TropicalRadiology, .^8-53. London; Hcineniann.Cockshott. W.P.. and A.O. Lucas. 1964. Radiological l-indings inHistoplasma duhoisii Infections. British Journal of Radiology, .17:65.3-660.Dalrymple-Champneys. W. I960. Brucella Infection and UndulantFever in Man. London: Oxford University Press. Zagrrb Paleopat/iology Symp. 1988 22 ? Don R. Brothwell Fcnncr, F. 1971. Infectious Disease and Social Change. MedicalJournal of Australia. 1;I043, 1099.Fiennes, R. 1967. Zoonoses ofPrimates. London: Weidenfield andNicolson.1978. Zoonoses and the Origins and Ecology of HumanDisease. London: Academic Press.Grmek, M.D. 1983. Les Maladies a I'Aube de la Civilisation Occi-deniale. Paris: Payot.Halpin. B. 1975. Patterns of Animal Disea.se. London: Bailliere,Tindall and Cox.Hungerford, T.G. 1959. Diseases ofLivestock. London: Angus andRobertson. Keymer. LF. 1958. A Survey and Review of theCauses of Mortality in British Birds and the Significance of WildBirds as Disseminators of Disease. Veterinary Records, 70:7 1 3-720, 736-740.Lambrecht. F.L. 1967. Trypanosomiasis in Prehistoric and LaterHuman Populations, a Tentative Reconstruction. In D. Brothwelland AT. Sandison, eds.. Diseases in Antiquiry. 132-151.Springfield, 111.: Charles C Thomas.McClure, H.E. 1963. Birds and the Epidemiology of Japanese En- cephalitis. Proceedings of the 13th International OrnithologicalCongress, 604-610.Nurse, G.T.andT. Jenkins. 1977. Health and the Hunter-Gatherer.Monographs in Human Genetics. 8. Basel, Switzerland: Karger.Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho-logical Conditions in Human Skeletal Remains. SmithsonianContributions to Anthropology. 28. Washington. D.C.: Smithso-nian Institution Press.Rankin, J.D., and A. McDiarmid. 1968. Mycobacterial Infectionsin Free-Living Wild Animals. InA. McDiarmid, ed.. Diseases inFree-Living Wild Animals. 119-131. London: Academic Press.Schwabe, C.W. 1964. Veterinary Medicine and Human Health.Baltimore: Williams and Wilkins.Shelley, C.E., ed. 1892. The Relations ofthe Diseases ofAnimals to Those of Man. Transactions of the Seventh International Con-gress of Hygiene and Demography, London, 1891. London: Eyreand Spottiswoode.White, E.G., and F.T.W. Jordan. 1963. Veterinary Preventive Med-icine. London: Bailliere, Tindall and Cox.World Health Organization. 1962. Milk Hygiene. World HealthOrganization Monograph. 48.Zammit, F. 1961. Brucellosis. In H Middlemiss, ed.. TropicalRadiology, 54-60. London: Hcinemann.Zimmerman, M.R. 1980. Aleutian and Alaskan Mummies. In A.Cockbum and E. Cockburn, eds.. Mummies, Disease and An-cient Cultures. 1 18-134. Cambridge, U.K.: Cambridge Univer- sity Press. Summary of audience discussion: Morphologic bone alterationsin a bacterially infected host occur only if host resistance is suffi-cient to allow survival over a period long enough to allow produc-tion of the destructive and responsive skeletal changes. The routineabsence of such changes in viral infections, together with the needof at least the more virulent viruses for a large, nonimmune popula-tion to maintain them, suggests that viral infections are more recentand therefore may have played a lesser role in the evolutionaryhistory of infectious diseases. Some interesting recent reports sug-gest that viral agents may trigger erosive arthropathies and theremay be a relationship of distemper to Paget's disease.A thorough search of ancient North American bison bones couldmake a major contribution to the question of whether bovine tuber-culosis in the New World preceded or followed the human form.Tuberculosis could have developed in zoonoses in very early peri-ods, been lost, and emerged again in later zoonoses. We also needmore precise information of brucellosis-generated bone changes sowe may search for them in archeological samples and trace the dairyproduct-linked diseases. Zagreb Paleopathology Symp. t9fiH Tuberculosis and leprosy: Evidence forinteraction of disease Keith Manchester Leprosy and tuberculosis are chronic infective diseases ofmankind, caused by bacteria of the genus Mycobacterium.Tuberculosis is not solely a human disease, but is also en-countered in lower mammals, in birds, and in certain cold-blooded animals. In contrast, although a leprosy-like diseasehas been identified in chimpanzee and in "wild" armadillo, asan important and relevant epidemiological entity it is essen-tially a human disease. Historically, on current evidence,both infections are relative newcomers to the spectrum ofhuman disease. Perhaps more than any other disease in hu-man history, leprosy has generated strong social reaction,which persists overtly or as undercurrent in many parts of theworld today, has stimulated legislation, and given rise toabhorrence. These emotive aspects of disease have spannedmany centuries. The reactions at epidemics of plague were,undoubtedly, of greater intensity, but these were short-livedand, in themselves, were epidemic. It is likely therefore thatthe manifold reactions and opprobrium of leprosy were dueto the chronicity of the disease, its mutilating and pitifulpresentation, and to ill-founded theology. But, to what extentthis last was a reactive root is not known; Christian and non-Christian medieval communities both practiced segregationand demonstrated ambivalence of attitude, harsh and benefi-cent, toward the leprosy sufferer. Tuberculosis was the sub-ject of Touching for the King's Evil in the European MiddleAges, but little other public reaction was engendered. Interms of mortality, tuberculosis was the "Captain of all themen of death."Bacteria of the genus Mycobacterium are responsible formore human suffering and misery than any other bacteria.Both tuberculosis and leprosy are eliminated as serioushealth problems in Western Europe and yet. in past centuriesboth were of immense significance therein. Today both arc still of immense significance in many parts of the world,particularly the tropics and subtropics. In Western Europe,the increasing eradication of tuberculosis is due largely toimproved socioeconomic conditions and, more particularly,to prudent public health measures. Eradication of bovinetuberculosis, mass immunological screening of juveniles,and appropriate vaccination are eliminating the disease. The Zagreb l^leopaihology Symp. 1988 demise of tuberculosis is, therefore, due to human agency.Not so with leprosy. The changing patterns in leprosy preva-lence and in clinical intensity have been, and to some extent still are, totally independent of any human activity directedtoward control and eradication.This paper seeks to review the history of tuberculosis andleprosy in antiquity and to consider the historic changingpatterns within the concept of modern epidemiology andimmunology. Bacteriology The bacteria responsible for the human diseases of leprosyand tuberculosis are members of the genus Mycobacterium.This genus, which contains about 30 species, is characterizedby the ability of the bacilli to retain staining by fuchsin and related bacteriological stains in the laboratory after exposureto weak acids. This acid-fast property is not, however,unique to the mycobacteria. Of greater genus specificity andtaxonomic value is the nature of the lipids within the bacterial cell walls. It is likely that the virulence or pathogenicity ofeach species is intluenced by the specific lipid content. It isalso likely that the host immunological response to invasionby the bacteria is infiuenced by the lipid content.Of all the mycobacterial species, M. leprae is unique inthat it is not possible, with present laboratory methods, toculture the bacterium in vitro. As a pathogen, its natural hostis mankind, although, as noted, a leprosy-like disease hasbeen recorded in chimpanzee and armadillo. Antigenically.M. leprae has been shown to be related to M. vaccae. anenvironmental saprophyte (Grange 1980:30). An evolution-ary significance of this finding has not, as yet, been demon- strated.M. tuberculosis, in common with all other mycobacteriaexcept M. leprae, is culturable in vitro. M. tuberculosis is.however, unique among the culturable mycobacteria in pos-sessing no environmental saprophytic strains. It is an obli-gate pathogen. Many of the other culturable mycobacteriamay be responsible for disease in man or animals, and Col-lins and Grange (1983:18) remark that not all mycobacteria23 24 ? Keith Manchester isolated from clinical material are tubercle bacilli. Such bac-teria may be regarded as opportunist pathogens.At present, there is not total agreement on the taxonomy ofthe bacilli causing tuberculosis in man and in cattle. Onetaxonomic opinion regards the responsible mycobacteria asseparate species, M. tuberculosis, M. bovis, and M. afri-canum. Alternatively, these are considered to be variants ofthe single species M. lubenulosis. and there are noted to befive recognizable variants of this species (Collins and Grange1983:19). Differentiation, regardless of taxonomic debate, isbased on in vitro growth characteristics, aerobic status, andenzymatic properties (Grange 1980:22; Collins and Grange1983: 17), but differentiation into these separate strains has no clinical value.However, while the dialectic of taxonomy may be relevantto the evolution of tuberculosis as a human disease, the im-munity induced by infection by the various bacilli is commonto them all. Immunology The basis of host defense against infection is twofold: innatenonspecific immunity, and acquired specific immunity.Natural or innate immunity is not directed at any specificinvading organism. It is of multifactorial component andconsists of biological host factors such as secretory and me-chanical barriers to invasion by pathogens, bactericidal prop- erties of body fluids, phagocytic cellular activity, and deter-minants such as general health and nutritional status, age,and hormonal balance (Weir 1986:42-44). It is thus depen-dent upon the milieu inteheur. In socioeconomically unsta-ble archaic communities this innate immunity must surelyhave played an important role in the epidemic and endemicinfections of antiquity. This is mirrored today, perhaps, in thefamine and war-torn peoples of the Third World, and theattendant endemic and fulminating epidemic infections.But it is the second immune mechanism which is of partic- ular interest in M. leprae and M. tuberculosis interrelation- ship. This is the acquired mechanism of adaptive immunity,characterized by memory, specificity, and the recognition of "non self" (Roitt 1980:1). The recognition of non self isaxiomatic and refers to the specific antigens, in the presentcase M. leprae and M. tuberculosis. Memory too is implicit;exposure to the specific pathogen (antigen) induces long-term host protection to future infection and development of clinical disease. Specificity in the immune response dependsprincipally upon the host synthesis of antibody (immu-noglobulin) to a specific antigen and its release into the bloodand other body fluids. This is the very basis of humoralimmunity. There is no evidence that humoral immunity playsany significant role in the defense mechanisms against my-cobacterial infection. It is another distinct acquired immunemechanism which is active in mycobacterial infection: cellmediated immunity (CMI). M. leprae and M. tuberculosisare intracellular facultative parasites inducing, ipso facto. LEPROMATOUS TUBERCULOIDFigure 1 . The spectrum of immunity and clinical disease inleprosy. (After Jopling 1982:296) pathological change and clinical disease. Upon invasion ofthe body, the mycobacteria are ingested by phagocytic cells(macrophages), and the bacterial intracellular faculty stimu-lates action by T lymphocytes. The stimulated T lympho-cytes produce and release a biologically active moleculecalled lymphokine. Within this group of substances are fac-tors which influence the activity and movement of mac-rophages. The macrophage so influenced produces a greaterintracellular content within itself of lysosomal enzyme. Thisincreased enzyme content heightens the ability of the mac-rophage to kill intracellular parasites contained within it.This, the basis of CMI, and considered very superficiallyhere, is complex when applied to A^. /cprac infection with thebroad immune, and consequent clinical spectrum. In tuber-culosis, host immunity is absolute; clinical response to infec-tion is not dependent upon and modified by a gradation ofimmunity, either innate or acquired. By contrast, it has beendemonstrated (Ridley and Jopling 1966; Jopling 1982:296)that there is a spectrum of host immunity to M. leprae infec-tions, and it is the status of the individual within this spec-trum which determines the severity and type of clinical dis-ease, and its infectivity, within the individual (Figure 1 ). Theconcept has also been applied in paleopathology (Andersen1982:223). At one end of the spectrum is the state of absenceof immunity, that is, low resistance to the pathogenic effectsof invasion by M. leprae. The resultant clinical disease islepromatous leprosy, a multibacillary condition charac-terized by high infectivity. At the other end of the spectrum isthe state of high immunity, or high resistance to the pathogen.In this state the clinical disease is tuberculoid leprosy,paucibacillary and of low infectivity. There is gradation of clinical presentation and infectivity between these extremes.Indeed, beyond the high-resistant tuberculoid end of thespectrum lies the concept of subclinical infection, a state ofnoninfective bacterial presence within the host, but withoutpathological manifestation. Paleopathologically, the low- resistant, lepromatous or near lepromatous state is uniquelydifferentiated by its development of rhinomaxillary change(Andersen 1982:223). It is a reality, dependent upon such Zugrel) Paleopalhology Symp I'iHS Tuberculosis and leprosy: Evidence for interaction of disease ? 25 factors as pregnancy, intercurrent infection, and malnutri-tion, for an infected individual of relatively high resistancetype of leprosy to downgrade toward the lepromatous pole.This concept of immune spectrum is of epidemiological im-portance and is of significance in the history and develop-ment of leprosy.However, the immunity in the cell mediated response isnot absolutely specific. Mackaness (1967:337) has demon- strated that the simultaneous exposure of /W. titherculosis andanother bacillus, Listeria monocytogenes, to a host sen- sitized by previous exposure to M. tuberculosis induces im-munity to both pathogens. The lone exposure of L. mono-cytogenes to the M. tuberculosis-sensiiiicd host does not,however, induce immunity. It is the dual and coincident ex-posure which is significant in immunity induction. To whatextent this duality of exposure and immunity applies in M.leprae and M. tuberculosis in clinical context is not, at pres- ent, known. If the same conditions apply as in M. tuber-culosis and Listeria invasion, then there may be relevance tohuman exposure and immunity in the medieval period inBritain when both infections were present and when tuber-culosis was of increasing incidence.A further response of CMI, of diagnostic significance intuberculosis and of pathological tissue significance in bothleprosy and tuberculosis, is delayed hypersensitivity reac-tion. This reaction in which granulomata, lesions typical ofleprosy and tuberculosis, are induced, is not considered sig- nificant in the present discussion of bacterial interrelation- ship.Within the context of immunity, prophylactic immuniza-tion by Bacille Calmette Guerin (BCG) is relevant to tuber-culosis and to leprosy. BCG, produced from M. hovis. is usedin clinical circumstances to induce immunity to tuberculosisin persons demonstrated by Mantoux hypersensitivity testingto be nonimmune to the infection. The phenomenon of BCGimmunization does, itself, demonstrate the phenomenon ofmycobacterial cross specificity, since the vaccine is not pro-duced from M. tuberculosis but is produced from M. bovis. asubspecies or variant. In clinical trials in areas of the world inwhich leprosy is endemic, BCG immunization has a proven,but variable, efficacy in the prevention of leprosy. The rangeof variability is from 20% efficacy in a Burmese trial to 80%efficacy in Uganda. Fine ( 1984: 147) suggested a number ofreasons for this variability. Differences between these popu-lations exhibiting such diverse BCG efficacy may, in part, beattributable to a degree of immunity to leprosy acquired bycontact with environmental mycobacteria. Administration ofBCG vaccine to a people already in possession of such partialimmunity may merely augment the overall population immu- nity to leprosy, and indeed to tuberculosis also, therebyfalsely overestimating the value of BCG vaccination.In summary, the acquired defensive mechanism in tuber-culosis and leprosy is CMI. The immune reaction is notabsolutely pathogen specific, but a degree of cross immunitybetween the pathogens is noted. Delayed hypersensitivity Zagreb Paleopathology Symp. 1988 reaction is of significance in the development of post primarytuberculosis and probably in the granulomatous developmentin leprosy. Genetic immunity is of unknown, but probablylittle, significance in leprosy and tuberculosis. Innate immu- nity is a nonspecific entity and is dependent upon biologicaladaptive mechanisms in the host to environmental and meta-bolic change and to intercurrent infection.There is no evidence to suggest that the bacteria responsi-ble for the clinical diseases of leprosy and tuberculosis werein any way different in antiquity from those of today. Neitheris there evidence to indicate that the immunological mecha-nism of the host to bacterial invasion has changed throughtime. It is temporal change in the immunological status of popu-lations, modified by previous bacterial exposure, which is, inpart, the basis of the present hypothesis. Epidemiology Because, in the main, tuberculosis and leprosy are diseasesof the undeveloped and developing nations, in which statis-tics are either absent or unreliable, the prevalence of thesediseases in the world at the present time is not known. It isestimated, however, that there are 1 1 .5 million cases of lep-rosy (World Health Organization 1985:10), although it issuggested (Andersen 1987) that the figure may be nearer to20 million. The total number of persons with tuberculosis isnot known, but it is estimated that 10 million persons developtuberculosis each year and at least 3 million die of the disease(World Health Organization 1982:10).Against this stark statistic it is necessary to consider as-pects of the epidemiology of these two diseases. Much of thedata are determined from current practice with only minimalinput from paleopathological studies. Because, as osteoar-cheological evidence indicates, there has been no change inhost tissue response to infection by M. tuberculosis or M.leprae, and there has, thereby, been no change in clinicalpresentation through time, it is considered justifiable to ex-trapolate current epidemiological data to archaic popula-tions. The inherent risks in moving from the known to theunknown are accepted. TRANSMISSION AND DEVELOPMENT There are, essentially, two portals of entry of the organismscausing tuberculosis in man: ingestion of bacilli or inhalationof bacilli. Reference to the taxonomic debate on A/, bovis andM. tuberculosis has already been made, and the irrelevanceof this in immunology is noted. However, in terms of trans-mission, and in the context of a hypothesis of historic devel-opment of disease, the two bacilli, be they strains or species, are of significance. Transmission of M. bovis is via the gas-trointestinal tract from the ingestion of cattle meat or milkinfected with M. bovis. The primary tuberculous lesion istherefore in the gut. Transmission of M. tuberculosis is via 26 ? Keith Manchester the respiratory tract from inhalation of droplets infected byM. tuberculosis and exhaled by a person with open, infec-tious, pulrnonary tuberculosis. The primary lesion is there-fore in the respiratory tract, either tonsillar bed or, morecommonly, lung. Because of this mode of transmission, pul-monary tuberculosis may be considered to be a populationdensity-dependent disease (v.i.).The incubation period, that is the latent interval betweenimplantation of bacillus and the development of clinical dis-ease, in tuberculosis is long. Dependent upon the course ofdevelopment of tuberculous infection, the incubation periodmay vary from two years to several decades. In terms ofimmunity, these figures are largely meaningless and dependupon interpretation of clinical disease. The first manifesta-tion of infection, termed primary tuberculosis, consists of aninfected lesion at the site of entry of bacilli, and associatedinfective change in regional lymph nodes. This state, whichmay be without clinical symptoms, is associated with thedevelopment of immunity to further infection. Thereafter,and dependent upon such other factors as general health sta-tus, there may be complete resolution of the primary complexbut with maintenance of immunity. Survival of the individualand restoration of total health ensues. The end result is ahealthy person immune to tuberculosis and, in some mea-sure, to other mycobacterial diseases. Alternatively, the pri-mary infection may progress as a disseminated, fulminating,and fatal disease with distant organ involvement or miliarylesions. Whatever the mortal presentation, these individualsare removed from the scene of population immunity and are,therefore, irrelevant to the present discussion. Those individ-uals surviving the primary lesion and restored to health may, at some future date, subject to a deterioration of generalhealth status or to the development of intercurrent infection.develop progressive tuberculous disease. This post-primaryor secondary infection may be the result of reactivation ofquiescent primary lesions, or the result of reinfection by thepathogenic organism. The difficult differentiation in theetiology of post-primary tuberculosis between reactivation orreinfection is of significance epidemiologically and may beof significance in the history of the disease. The endogenousor exogenous .source of bacilli is of no significance in theclinical course of the disease or in immunological status.Post-primary infection is the familiar disease of adulthood,characterized pathologically by progressive granulomatousand caseating lesions, and clinically by progressive emacia-tion, cough, dyspnea, and hemoptysis in pulmonary diseaseand abdominal pain, distension, and pyrexia in gastrointesti- nal disease. Subsequently, other organ involvement may en-sue, and bone and joint infection are of major importance inosteoarcheology.To repeat and stress however, it is the primary infection intuberculosis, with tuberculin conversion indicating immu- nity, which is of significance in the immune profile of thesurviving individual and, through his place therein, of thepopulation as a whole. After many years of uncertainty, it has now been demon-strated that the clinically important mode of transmission ofM. leprae is by inhalation of infected droplets from a leprousindividual harboring bacilli in his nasal mucosa (Jopling1982:295). Transmission of leprosy is, therefore, largelyfrom individuals with multibacillary disease, that is, thosefrom the low-resistant end of the immune spectrum. The criteria for such infectivity is the presence of a "highlybacilliferous nasal discharge" (Pedley and Geater 1976:97).The infectivity of paucibacillary. tuberculoid leprosy is slight. In contrast to earlier thought, it is now considered thatleprosy, from Icpromatous cases, is a highly infective dis-ease, but that, because of the immune status, only a smallproportion of people infected with the bacillus actually de-velop clinical disease.The incubation period of leprosy is. like tuberculosis, ofuncertain and long duration, probably between two and sev-en years (Jopling 1982:296).Unlike tuberculosis, the pathogenesis of leprosy is notbiphasic. There is no primary and secondary complex inleprosy. As previously noted, M. leprae is an intracellularpathogen, and has an affinity for Schwann cells of peripheralnerves and for cells of the reticuloendothelial system. Afterinfection, tissue change and consequent clinical disease isprogressive, modified only by the immune status, andchange therein, of the host. Although, as yet. the stage ofdevelopment of acquired immunity in leprosy is incom-pletely understood, it has been demonstrated by immunolog-ical testing in Micronesia and Sri Lanka that an immunity hasdeveloped from three months to two years before the onset of clinical disease (World Health Organization 1985:23).Leprosy, unlike tuberculosis, is generally not a fatal dis-ease. It is a relentlessly progressive and mutilating disease,but further discussion of the clinical symptoms and signs ofthe disease is beyond the scope of this paper. AGE In tuberculosis, the development of CMI is coincident withthe pathological changes of primary infection. Tuberculinsensitivity is a codevelopment of CMI. albeit associated withantibody production, itself of little significance in the tuber-culous defensive mechanism. Tuberculin sensitivity conver-sion can however be taken as a guide to the acquisition ofimmunity and, as a corollary, to the period of primary infec-tion. Unfortunately, the age of conversion is incompletelyknown for modem developed nations and is almost com-pletely unknown for undeveloped nations. It follows, by na-ture of the evidence, that the age of conversion can never beknown for archaic peoples. Neither, of course, can it beknown for more recent peoples before the advent of tuber-culin sensitivity testing. Some other guide to primary infec-tion, appropriate, by extrapolation, to archaic peoples mustbe used.If the death rate from tuberculosis, by year of death, is Ztij^reb Paleopathology Symp. I98H Tuberculosis and leprosy: Evidence for interaction of disease ? 27 examined from the prechemolherapeutic era, it is noted (Fine1984: 14 1 ) that the highest mortality occurs before the age offive years, failing dramatically thereafter and rising againmarkedly in the third decade (Figure 2). This may be inter-preted as a high infant mortality associated with primaryinfection and a further high and sustained mortality withfwst-primary infection, if these late 19th century data can beassumed representative of medieval populations, then initialexposure to M. nihcnulosis and the development of primaryinfection and consequent immunity occurred during infancy.Because the ELISA test for leprosy infection is a relativelyrecent introduction which has not. as yet, had a wide applica-tion in epidemiology, age patterns in leprosy can be deter-mined only in relation to clinical disease. The age of in-fection and, in consequence, the age of development ofimmunity, are unknown. However, the age of infection is,post hoc propter hoc, dependent upon the age of contact of anindividual with an infective case. It is also dependent uponthe intimacy of contact (v.i.). In infected families youngchildren are likely to have more intimate contact than olderindividuals, and therefore the young are more likely to be-come infected (Badger 1964:84). Clinical disease is rarelyencountered below the age of five years. The incidence then rises to a plateau in the fourth decade. With acceptance of thelong and variable incubation period, it seems likely that theage of infection in leprosy may be somewhat later than thatfor tuberculosis. Thus the age of development of acquiredimmunity may, likewise, be somewhat later. 700- 600- 500-ooo crLlJQ- a:I< 200100- 20 30 40 50 60 70AGE AT DEATH(IN YEARS) Figure 2. Tuberculosis death rates by yearof death, late 19th century, Massachusetts.(After Fine 1984:141) SEX Although variations according to age and sex in incidence rates of both tuberculosis and leprosy as clinical diseases areknown, it is considered that the sex variation has little bear-ing on the proposed immunological interrelationship. Furtheranalysis is, therefore, not relevant within this paper. POPULATION DENSITY Leprosy has been described as a "disease of the villages"(Hunter 1986:5). But against this generalization, there isconsiderable evidence that household contacts of patientswith lepromatous disease are at a high risk of infection.Epidemiological studies in Burma, South India, and the Phil-ippines has indicated a familial clustering of infection (WorldHealth Organization 1985:23-24). It is noted (Badger1964:72) that the more intimate the contact the greater the risk of infection, and the risk of infection is greater withintrafamilial than with cxtrafamilial contact. In keeping withthis, the rate of infection is also influenced by the number ofcontacts to whom an individual is exposed. Such interpreta-tion of familial susceptibility is also complicated by the influ-ence of socioeconomic status, hygiene, nutrition, and a "ge- netically determined susceptibility" of blood relatives.Studies suggest that there is an association between crowding Zagreb Paleopalhology Symp. 1988 and leprosy, but the problems of poverty and mobility ofpeoples further complicate the picture. The inhalation modeof transmission of A/, leprae suggests that crowding of peo-ples and intimacy of contact are important epidemiologicalfactors. Therefore, it is expected that leprosy is a disea.se of village and urban communities alike.Buikstra and Cook ( 1 98 1 : 1 1 8) described tuberculosis as apopulation density-dependent disease, and Cockbum ( 1963:88)also considered the disease to be a crowd disease of urban society. However, with regard to the different modes of trans-mission of M. bovis and M. tuberculosis and, in conse-quence, to the diHerent primary manifestations and immu- nity therefrom, the relation, in immunological perspective,of infection to pt)pulation density may be twofold. Primarygastrointestinal disease caused by M. bovis is dependentupon human contact with an animal reservoir of tuberculousbeast. Herd size, not human population size, is the criticalfactor for cndemicity of human primary gastrointestinal tu-berculosis (Manchester 1986). Thus, this disease is likely to atTect urban and rural peoples alike, assuming the generalavailability of milk and flesh. The growth of markets inmedieval towns and cities in Britain is likely to favor urbanexposure. Pulmonary tuberculosis is, in contrast, entirely 28 ? Keith Manchester dependent upon contact with a fellow human with open in-fectious disease. Pulmonary tuberculosis is, therefore, acrowd disease of population density dependence. It is, ofcourse, possible, particularly within the confmes of the com-munal animal-human ionghouse, for pulmonary infection viainhalation of M. hovis to develop from intimate contact withan "open" cattle infection. It is further acknowledged thatpost-primary infection, irrespective of primary focus, maybe achieved by ingestion or inhalation. But, as already stated, it is the primary infection, and the immunity devel-oped thereby, which is significant to the arguments of thispaper. It is proposed therefore that, in antiquity, there was abaseline of M. bovis primary infection which was sporadicand totally independent of human population size. In addi-tion, as primary disease, and superimposed as post-primarydisease, there was M. tuberculosis infection. This was de-pendent upon population density, and followed and was acon.sequence of urbanization and aggregation of peoples intrade. It is unfortunate but, notwithstanding the pulmonarytuberculous interpretations of rib lesions by Kelley andMicozzi (1984), paleopathological differentiation of pulmo-nary and gastrointestinal disease cannot, as yet, be made.The above comments on the archaic implications of M. bovisand M. tuberculosis have not, therefore, been investigated orproven. SOCIOECONOMY Both tuberculosis and leprosy are diseases associated, ingeneral terms, with poverty, poor nutrition, and poor generalhealth status. Badger (1964:73) remarks that, in leprosy, "thegreatest prevalence has been, and remains, among peoples oflow economic status, with inadequate housing etc., whichleads to crowding and intimate contact." In the paleopathol-ogy of tuberculosis, a demonstration of these factors has yetto be made. In the paleopathology of leprosy, M0ller-Christensen (1978: 1 17) reported that 69.7% of leprous skel-etons from Naestved exhibited cribra orbitalia, while only20.2% of contemporaneous nonleprous skeletons fromi>i(' unii Anthropologie . l.'il'i.Angel, J.L. 1964. Osteoporosis; Thalassemia? AmenVn/iy^x/rna/o/Physical Anthropology. 4 1 : 103- 1 06.1966. Porotic Hyperostosis, Anemias, Malarias and theMarshes in Prehistoric Eastern Mediterranean. Science,153:760-762.1967. Porotic Hyperostosis or Osteoporosis Symmetrica.In D. Brothwcl! and A.T. Sandison. eds.. Diseases in Antiquity,378-389. Springfield, 111.: Charles C Thomas.Armelagos, G.J., D.S. Carlson, and D.P. van Gervcn. 1982. TheTheoretical Foundation and Development of Skeletal Biology. InF. Spencer, ed.. A History of American Physical Anthropology1930-1980. 305-328. New York; Academic Press.Carlson, D., G.J. Armelagos, and D. van Gervcn. 1974. FactorsInfluencing the Etiology of Cribra Orbitalia in Prehistoric Nubia.Journal of Human Evolution, 3:405-410.El-Najjar, M. . D.J. Ryan. C.G. Turner II. and B. Lozoflf. 1976. TheEtiology of Porotic Hyperostosis Among the Prehistoric and His-toric Ana.sazi Indians of the Southwcstem U.S. American Jour-nal of Physical Anthropology. 44:477-488.Hengen. OP. 1971. Cribra Orbitalia: Pathogenesis and ProbablyEtiology. Homo. 22:57-75.Hrdlicka. A. 1914. Anthropological Work in Peru in 1913, withNotes on Pathology of Ancient Peruvians. Smithsonian Mis-cellaneous Collections, 61:1-69.Lallo. J.. G.J. Annelagos, and R.P. Mcnsforth. 1977. The Role ofDiet. Disease and Physiology in the Origin of Porotic Hyper- ostosis. Human Biology. 49:471-483. Zafireb Paleopathology Symp. 19HH l\)rotic hyperostosis: Changing inteqDretations ? 39 Lukens. J. 1975. Iron Deficiency and Infection. Amerkon JoiinutIof Diseases of CliiUtren , 1 29; 1 60- 1 62 . Mensforth. R.. C. Lovejoy, J. Lallo, and G.J. Armclagos. 1978.The Role of Constitutional Factors. Diet, and Infectious Diseasein (he litiology of Porotic Hyperostosis and Periosteal Reactionsin Prehistoric Infants and Children. Medical Anthropology, 2: 1 -59.Moscley, J.E. 1961. Skull Changes in Chronic Iron DeficiencyAnemia . American Journal ofRoenlgenolofiy ami Radium Thera-py. 85:649-652.Moore. S. 1929. Bone Changes in Sickle Cell Anemia with Note onSimilar Changes Observed in Skulls of Ancient Mayan Indians.Journal of Missouri Stale Medical Association, 26:561-564.Nathan. H. andN. Haas. 1966. The Presence of CribraOrbitalia inApes and Monkeys. American Journal ofPhysical Anlhnipoloiiy.24:351-360.Owen. R. 1859. Report on a Series of Skulls of Various Tribes ofMankind Inhabiting Nepal. Collected and Presented to the Muse-um by B.H. Hodgson. Report British Association. London.Powell. M.S. 1986. Bone Lesions of Chronic Disease: A Caution-ary Note for Interpretation. Paper presented at the 55th annualmeeting of the American Association of Physical Anthropology,Albuquerque. New Mexico.Scrimshaw, N. 1964. Perspectives in Nutrition. American Journalof Clinical Nutrition . 14:112-122.Strauss. R. 1978. Iron Deficiency. Infection, and Immune Function:A Reassessment. American Journal of Clinical Nutrition.31:660-666.Stuart-Macadam, P.L. 1982. A Correlative Study of a Pal-aeopathology of the Skull. Ph.D. dissertation. Department ofPhysical Anthropology, Cambridge University, Cambridge,U.K. 1985. Porotic Hyperostosis: Representative of a ChildhoodCondition . American Journal ofPhysical Anthropology. 66:39 1 -398. 1987a. Nutrition and Anaemia in Past Human Populations.Chacmoal. Alberta, Canada: University of Calgary.1987b. A Radiographic Study of Porotic Hyperostosis.American Journal of Physical Anthropology. 74:5 1 1 -520. Ubelaker, D.H. 1984. Prehistoric Human Biology of Ecuador: Pos- sible Temporal Trends and Cultural Correlations. In M.N, Cohenand G.J. Armelagos, eds. , Paleopathology at the Origins ofAgri- culture. 491-513. New York: Academic Press.Wadswonh, G.R. 1975. Nutritional Factors in Anemia. World Re-view of Nutrition and Dietetics. 2 1 :75- 1 50.Walker, PL. 1986. Porotic Hyperostosis in a Marine-DependentCalifornia Indian Population. American Journal of Physical An-thropology. 69:345-354.Welcker, H. 1888. Cribra Orbitalia, ein ethologisch-diagnostischesmerkmal am schadel mehrerer menschrassen. Archive fur An-thropologie. 17:1.Williams, H. 1929. Human Paleopathology. Archives ofPathology,7:839.Wood-Jones, F. 1910. General Pathology (Including Diseases of theTeeth). In G.F. Smith and F. Wood-Jones, eds.. Report on theHuman Remains. The Archaeological Survey of Nuhia. Reportfor 1907-1908. vol. 2. Cairo. Summary of audience discussion: Porotic hyperostosis presentsproblems of both diagnosis and etiology. Minor osteoporotic pittingor outer table erosion above the temporal lines and on frontalsquama as well as above the occipital crest without frank thickeningshould probably be given a descriptive label which does not bear the etiological implications presumed for porotic hyperostosis. Site specificity can also be a problem. While the material reviewed inthis presentation demonstrated involvement of both cranial porotichyperostosis and orbital cribra orbitalia in 90% of the individualsstudied, the range of such associations varies from to 100% indifferent groups. It should be remembered that porotic hyperostosisis an indicator of childhood, not adult, anemia, and that iron defi-ciency anemia may be the consequence of blood loss or pathologicalabsorptive conditions even in individuals consuming diets of nor-mally adequate iron content. Some orbital porous lesions appear tobe of infectious origin; in sickle-cell anemia the orbital cases occur at 4-5 years of age. Zagreb Paleopathology Symp. 1988 Diagnosis of occupationally relatedpaleopathology: Can it be done? Ann Stirland 1 he occupations followed by people in the past and the activities in which they most widely indulged have probablynot changed greatly until recently. The development of mod-em technology has brought changes in occupations, tooltypes and usages that may in time produce characteristicskeletal variations. There are already reports in the clinicalliterature relating such changes to occupation (Mintz andFraga 1973). In the past, activity-related pathology may havebeen expressed as stress fractures of the tibia in hunter-gatherer groups which "ran down" their large prey. No matterhow good the preservation and recovery of artifacts from anarcheological site, however, the interpretation of their useand the activities involved relies heavily on assumptionsbased on ethnographic and historical parallels. Such interpre-tation is speculative. It is a truism that an archeological site usually has nodocumentary records. The occupations and activities of itspopulation are, therefore, unknown except from their ar-tifacts. Paleopathological diagnosis brings its own problems.Human bone has only two responses to any insult: eithernormal bone is lost or new bone is added. Such limited re-sponses lead to difficulties in equating specific pathologicallesions with particular occupations. Hven in a modern clini- cal context diagnosis is an inexact science, and many of therelationships between occupation and pathology are still notclearly understood. Much occupational pathology will beconfined to soft tissue and will leave no record on the skel-eton. There is also the problem of distinguishing lesionswhich are attributable to a direct traumatic event, age de-generation, or developmental defects from those specifically related to occupation. Paleopathologists have only recently attempted to relatesome pathology to occupation, and they arc constantly madeaware of the problems and limitations of such interpretationof the material. There are, however, some positive aspects.Unlike the clinician, the paleopathologist is working with thewhole dry skeleton. Changes in bone are seen in their veryearly stages and conditions which may be clinically symp-tomless can be detected.40 Occupationally related paleopathology is, by definition,nonrandom and habitual. If, despite the problems, some oc-cupations can be diagnosed then this will provide an impor-tant tool in archeological reconstruction. The ability to iden-tify some skills, trades or professions can lead to theextrapolation of this evidence into other sites and periods,making a further valuable contribution to archeology. Skeletal studies The only comprehensive skeletal study of activity-inducedpathology so far produced is that by Merbs ( 1983). Althoughthe Sadlermiut series analyzed was not particularly large,consisting of 41 male and 50 female adult skeletons, thegroup was thought to meet many of the necessary criteria forsuch a study (Merbs 1983:4,5). These include a limited num-ber of specialized, but known, activities, good skeletal pres-ervation and recovery, a relatively narrow time span, andboth cultural and genetic isolation. The paleopathologicallesions in the group were evaluated in six categories: os-teoarthritis, osteophytosis, vertebral compression, other de-generative features of the vertebral column (porosity of the articular body surfaces, Schmorl's nodes and laminal spurs),spondylolysis, and anterior tooth loss. The largest categorywas that of osteoarthritis. Merbs analyzed Sadlermiut ac-tivity patterns and discussed their possible stresses on areasof the skeleton (1983: 147-156). He correlated the patterns of activity and pathology. In his conclusions. Merbs argued thatthe osteophytosis of the vertebral columns is a normal de-generative condition and a consequence of bipedalism. Anumber of the other pathological lesions, however, were cor- related with particular activities, known or reconstructed.Both sex and side differences were shown to be important.Of particular interest were some elements of specific ac-tivities which had not been anticipated during Merbs's recon-struction of Sadlermiut behavior patterns. These elementswere suggested, however, by particular patterns of pathology(Merbs 1983:184). This unexpected result provides an op-timistic conclusion to the study and suggests further potentialfor such reconstruction. Zagreb Paleopalholony Symp. t*^HH Diagnosis of occupationally related paleopathology ? 41 Another activity-related skeletal study by Dutour (1986)postulates enthesopathies as indicators of activities in twoNeolithic populations. There are. however, problems withthis work. Both groups studied were small, consisting of only41 skeletons in total. Of these 21 were unsexable. Dutourdoes not differentiate between enthesis, attachments of mus- cles, and syndesmoses, attachments of ligaments (1986:224).He calls all his observed lesions enthesopathies althoughsome are in areas of ligamentous and not tendinous insertion.This is particularly important since it concerns his recon-struction of a possible archer (1986:222). Here, the en-thesopathies of the right radius have been combined withdegenerative changes to the synovial joints at both elbowsand with developments of muscle insertions on both humeri.All these changes are not enthesopathies and the synovialjoint changes may be age related. Dutour does not appear totake such age-related degeneration into account when dis-cussing the etiology of the lesions. It is clear, however, fromthe literature that enthesopathies are degenerative in natureand are "common in older individuals" (Resnick andNiwayama 1981:1297). Apart from using such categories as "juvenile," "mature adult" and, in one case, "aged male," noindication of age ranges is given. In attempting to diagno.seactivity-related changes, the relative ages of the individualsconcerned are of importance. When enthesopathies whichare not metabolic or inllammatory in origin are thought to bedegenerative in nature, then age becomes a key question.However, as the changes concerned may be accelerated bytrauma or chronic stress ( Resnick and Niwayama 1 98 1 : 1 3(X))and, therefore, activity, the picture may be more complexthan would appear from Dutour's paper. The problem is onceagain one of specificity.In a recent paper. Waldron ( 1 987) discussed a site in whichthere is some documentary evidence of occupation from buri- al registers. Although this work is only in its early stages it isof great interest. Of the 336 adults so far examined fromChrist Church. Spitalfields, 37.2% have osteoarthritis. Thisoccurs most commonly in the spine, but the shoulders andhands are also involved. The hands are of particular interestsince Spitalfields was a very important silk-weaving center,and the disease here may be related to occupational factors.One of the problems associated with the diagnosis of occu-pationally related pathology is concerned with current termi-nology. An example is the use of the term "degenerativechange." Some specialists use it to denote age-relatedchanges, while others are concerned with the deterioration ofjoint surfaces resulting in destruction or proliferation ofbone. Ortner( 1968: 141) studied two large skeletal groups inorder to classify degenerative change in the humeral elbow.This study uses the term in the latter sense and stresses theimportance of handedness, sex, and cultural practices in de-generative change. Ortner (1968:144) also emphasizes thesignificance of age in the degree of degeneration in a joint,and discusses mechanical stress, anatomy, and heredity asother determining factors. Zagreb Paleopaihotogy Symp. I98H These skeletal studies, while subject to inherent problems,do attempt to describe possible occupationally relatedchanges and to categorize some of them. Clinical studies The traditional clinical postulate has been that in os-teoarthritis, particularly of the spine, an occupational com-ponent is present. In the public as well as the specialist mind,pathology of joints has often been associated with usage.This is reflected in the popular terminology often associatedwith overuse syndromes, such as "tennis elbow." However,the modern clinical view of the role of activity in the develop-ment of osteoarthritis is, to say the least, ambivalent. Thetraditional view is represented by studies such as those oncoal miners (Lawrence 1955), dockyard workers (Andersonand Duthie 1963), and by some theoretical works (Radin et al. 1972). Other work, however, such as that by Hadler,presents a different view. In his first study, Hadler stresses theanecdotal nature of much of the clinical correlation between activity and some musculoskeletal disease, and points outthat the amount of true clinical information is somewhatinadequate. He suggests alternative strategies for clinicalstudies to gather the necessary information (1977:1023).These studies are implemented in later work on patterns of repetitive, stereotyped usage in the hands of female textileworkers ( Hadler etal. 1978; Hadler 1980). It is clear that thislater work considers degenerative joint disease to be a highlyprevalent process of aging throughout the entire population,and not confined to specific groups; repetitive, stereotypedtasks and side are both involved in the degenerative syn-drome.Anderson found in a study of manual workers that, afterallowing for age, heavier work significantly increased thelikelihood of rheumatic complaints in general and degenera-tive disc disease in particular, but not of osteoarthritis of theother joints (1974:523). He also concluded that such disea.sesare likely to develop earlier among heavy manual workers(1974:524). In a later study. Anderson identified the impor-tance of side, age, biochemical changes and their geneticbases, and chronic irritation in the development of os-teoarthritis (1984:431 ). He argued "that the development ofdegenerative changes can be triggered in those at risk" eitherby a severe impact which damages the cartilaginous jointlining, or by chronic stress over a long period producingfatigue in a joint. Both posture and mobility were seen to beimportant in these changes.Lockshin et al. (1969) surveyed arthritic complaints inmore than 1 1(K) men from three mining communities in WestVirginia. The main differences between the groups were thatin the 60-69 age group. 68.9% of miners had osteoarthritis ofthe cervical spine grades 2-4. conipared with 56.9% of non-miners (1969:24). Unlike similar British work (Lawrence1955). these authors found no difference in the prevalence ofdisc degeneration m the lumbar spine between miners and 42 ? Ann Stirland nonminers. This was attributed either to an unexplainedhigher prevalence in nonminers or to a difference in workingenvironments in the two countries. Similarly, in a Finnishstudy of lumberjacks, no correlation could be found betweenthe period of heavy work and disc degeneration when the agefactor was removed (Sairanen et al. 1981 ). The authors con-cluded that various factors seem to be involved in the etiol-ogy of disc degeneration, as well as age and mechanical stress. Heredity and autoimmunization may be involved inthese changes, making it difficult to assess the role of heavywork. Osteoarthritis was thought to have a multifactorialetiology (Sairanen et al. 198 1 :27), and ergonomically correctwork was found to be very important in its lack of develop-ment. Lindberg and Danielsson (1984) were also unable intheir study to demonstrate any relationship between occupa-tion and coxarthrosis in shipyard workers involved in heavylabor.Some of the preceding papers, and much of the fundamen- tal work in this field, are excellently reviewed by Hagberg(1984). In this review, the controversial nature of the etiologyof the degenerative arthropathies, the enthesopathies, andtheir relationship to occupational stress are clearly discussedand evaluated in the context of disorders of the neck andshoulder (1984:270-275). This work emphasizes what mustby now be clear. The role of occupational stress as a factor in osteoarthritis is far from unequivocal. This is partly a func-tion of the classification of work by occupation (e.g., "miners"), rather than by actual task or evaluation of stress,or by loading on skeletal areas. The necessary information isalso .spread over many different specialized medical fieldsand its interpretation can suffer from the constraints of differ-ing opinions.The changes due to osteoarthritis or to degenerative jointdisease are not the only ones that may be related to activity inthe skeleton. Lesions may be present whose pathogenesis isclear but in a different context. An example is the group ofenthesopathies. In this case, the lesion may be degenerative(related to age) in one context, but occur in a young, robustindividual in another. If direct trauma or disease can be elimi-nated as a causative agent, then another explanation has to befound for the lesions.Other morphological variants used as occupational stressmarkers are supinator crests and fossae of ulnae (Kennedy1983). The hypertrophy of the crests, deepening of the fos-sae, and "ridging" of the insertion of the anconeus musclewere found in prehistoric samples in males "known" to haveused missile weapons such as spears (Kennedy 1983:872).Similar changes also occurred in modem populations, in bothsexes, who were habitually engaged in occupational or ath-letic activities involving similar patterns of arm movement.Changes at the elbow which can be directly related to occupa-tion are also apparent in baseball players (Bennett 1959).Damage to hyaline cartilage, olecranon fractures, and spurformation occur as a result of persistent, chronic strain. Chronic bursitis and fraying of both supraspinatus and bicepstendons are recorded as a result of strain and overuse.The previous examples resulted in the formation of pro-liferative new bone at various sites in the upper girdle. An-other syndrome associated with activity-related stress is os-teolysis of the distal clavicle (Kaplan and Resnick 1986).This pathology is known to occur clinically after acute trau-matic injury to the shoulder. In the cases cited here, it wasalso found to occur secondary to repeated microtrauma of theacromioclavicular joint. The main case is of a 39-year-oldmale who worked in a bakery, lifting heavy pans of rolls inand out of ovens all day. There had been no single traumaticevent. Similar, atraumatic pathological changes have beennoted in other occupations involving loading, such as air-hammer operator or oxygen tank delivery man, and also in athletes, such as weight-lifters and handball players.The clinical existence and reporting of pathologicalchanges other than those associated with osteoarthritis in thehuman skeleton is encouraging. Although the arthropathiesare the most common pathological changes observed in ar-cheological skeletal material, other lesions do occur. Whilesome of these are truly pathological and are a consequence ofa disease process, others quite clearly are not. It is commonto attribute the term "pathological" to anything that is abnor-mal. Such abnormalities include some of the changes alreadydiscussed, such as the enthesopathies, and those due to over-use or activity. Can such abnormal changes be used in thediagnosis of occupationally related paleopathology? The Mary RoseOne of the more serious problems encountered in the analysisand interpretation of archeological human skeletal material isthe lack of spatial and temporal controls for a particular site.This problem is part of the wider one already referred to,namely, the general lack of any documentary evidence. Very rarely is a site excavated in which these problems are mini-mized. Such a site is Henry VIII's flagship, the Mary Rose.The Mary Rose was sunk on the morning of 19 July 1545 after having emerged from her home port of Portsmouth,England, at the head of the English fleet. The object was toengage the French fleet moored nearby. The ship apparentlyexecuted a bad turn to starboard and, in attempting to raise sail, took in water through open gun ports, heeled over andsank rapidly, settling heavily into the soft seabed silts. Of thecrew of 415 men all but about 35 drowned, including thecaptain, the master, and the vice admiral. Most were trappedunder the stout antiboarding netting which covered thedecks. The ship came to rest on her starboard side and siltedup within a matter of months. The exposed port side waseroded by the sea until it collapsed, leaving intact the com-plete starboard half. The wreck was then sealed in the 16thcentury by a hard, shelly seabed and remained hidden, apartfrom the occasional severe winter storm, until it was discov-ered in 1968. The rapid silting and sealing provided a perfect Zagreb Paleopathology Symp. 1 988 Diagnosis of occupationally related paieopatiiology ? 43 anaerobic environment in which much organic material, in-cluding the human skeletal remains, was exceptionally wellpreserved. The position and condition of the wreck led to acommingling of the skeletal material both within individualdeck sectors and probably, in some cases, from one deck toanother. An account of the finding, excavation, and raising ofthe Mary Rose may be found in Rule ( 1982. 1983).Henry VIll had a list of his ships compiled by AnthonyAnthony and this was completed in 1546 (Rule 1982:26-28).This list contains the only contemporary picture of the MaryRose and includes crew numbers and their occupations (Rule1982:27). It also includes lists of all the ordinance and equip-ment for the war. In the case of the men of the Mary Rose.therefore, the actual date and cause of death is known as istheir equipment and occupations. This sample, like Merbs'sSadlemiiut, meets many of the criteria for the study of ac-tivity- or occupationally related pathology. There is, how- ever, one problem that Merbs did not have; it is a very com-mingled group. Because of the unique nature of this sample,its importance and the possibility of undertaking such astudy, it was decided to try to re-sort the bones where possibleinto individuals. This was undertaken initially for the pur-poses of the bone report submitted in 1985. Because of pres-sure of time (money), the re-sorting was accomplished onlywithin the deck sectors and not attempted from one deck toanother. A skull and mandible count produced a minimumnumber of 179 individuals; the re-sorting generated 9 1 fairlycomplete skeletons, some more complete than others.Experience suggests that an archeological sample of hu-man remains generally displays a fairly common collectionof pathological lesions. Many of these lesions are expressedin joint changes as arthropathies. Apart from the arthropa-thies, healed fractures are commonly seen as in nonspecificperiostitis and. in the New World at least, porotic hyper-ostosis and cribra orbitalia. In some specific groups and timef)eriods, evidence for tuberculosis and for leprosy can beidentified. Other lesions occur generally much less com-monly in such material, although they may have a morewidespread clinical expression. They include such examples as osteochondritis dissecans, Osgood-Schlatter's and Scheuer-mann's diseases. There are other conditions, such as os acro-miale, which are very rare and have a low expression in anygroup, and there are morphological changes, such as theenthesopathies, which have a much higher frequency in somegroups than in others. In the sample from the Mary Rose, weare concerned with the last three groups rather than the morecommon ones.Predictably for a fighting ship, most of the men of theMary Rose were young and some of them were very young.There was a predominance of individuals ranging from 1 5 to25 years with a smaller group in their late twenties/earlythirties. There was also a very small number of both veryyoung (10-15) and older (35-45 + ) men. Before discussingthe patterns of pathology, it must he pointed out that, owingto the problems of mixing, pathology in this group has so far Zofireb Paleopathology Symp. 1988 been assessed by bone, rather than by individual. It is ac-cepted that, for the arthropathies at least, this situation isundesirable (Rogers et al. 1987). and discussion on arthriticchanges has, therefore, been omitted.The area of the skeleton displaying the most pathology isthe vertebral column. There are nine cases of spondylolysis,including one of spondylolisthesis but, apart from these,most of the lesions arc in the thoracic segment. The mostcommon of these lesions is Schmorl's nodes, and they occurin some subpubescent spines where the centra are still verybillowed and the epiphyseal ring is unfused. Such car-tilaginous nodes have a varied etiology (Resnick andNiwayama 1981:1404). If they are not degenerative or re-lated to various diseases, however, they are often a conse-quence of trauma. One of the diseases in which Schmorl'snodes occurs is Scheuermann's disease. This condition alsohas a high frequency in the sample, in the thoracic spine. As it is a juvenile condition, it occurs in very young spines,although the evidence is al.so retained in older individuals.Much of the modem work on Scheuermann's disease sug-gests that it is probably a manifestation of the node formationand a result of the failure of the cartilaginous end plate under stress which can be traumatically induced. In the samplethere are also marked changes in the shape of the centra in thethoracic spine, producing an expansion, often in an anteriordirection. Thoracic scoliosis is also apparent, as is twisting ofsome apophyseal joints, particularly at the lower end wherethere is also some gross enlargement of such joints. This isparticularly true in the case of three of the matched, fairlycomplete skeletons. They are all young, in their early to mid-twenties, and they all exhibit a great deal of stress to thethoracic and lumbar areas. One in particular has extraordi-nary vertebrae. All are large and robust with huge apophysealjoints, particularly TlO-12. Both Til and T12 look likelumbar vertebrae, with characteristic curved articulations(Figure 1), and the sacrum and innominates are also verylarge with deep articulations. All three of these skeletonswere found on the Main Gun deck in close association withone of the very heavy bronze cannon. These cannonsweighed up to two tons and were operated entirely by hand by a gun crew, being hauled in and out of the gun port on awooden carriage. The hall shot used was also very heavy andhad to be fetched in baskets from the Orlop deck below.Two other conditions which are a consequence of trauma resulting in damage to an epiphysis are osteochondritis dis.se-cans and Osgood-Schlatter's disease. Both are more frequent clinically in the young and both afTect boys more than girls.Neither are seen commonly in archeological samples. In thesample from the Mary Ro.se. there are high frequencies ofboth. The most common site for osteochondritis dissecans isthe first metatarso-phalangeal joint. There are 23 affectedbones: 1 6 examples occur on the distal humeral condyles and7 on the distal femoral condyles, some bilaterally (Figure 2).There are six cases, two left and four right, of unusual pitsoccurring in femoral heads, superior to the fovea (Figure 3). 44 ? Ann Stirland Figure 2. Bilateral osteochondritis dissecans. Figure 1 . Gross enlargement of lower tho- racic apophyseal joints (arrows). (All speci-mens illustrated in this paper are courtesy ofthe Mary Rose Trust.) Figure 3. Pits in femoral heads. These have also been identified as osteochondritis dissecans(I. Watt 1984, pers. comm.), although an alternative diag-nosis of avascular necrosis has been suggested (D. Birkett1986, pers. comm.). Eleven left and 12 right tibiae exhibitOsgood-Schlatter's disease. Some are very young with new-ly fused epiphysis and in some cases it is bilateral (Figure 4).Os acromiale is a rare anomaly which has already beendescribed for this group (Stirland 1987). The data in thisearlier paper have now been updated and the frequency is12.5%. With a normal frequency of from 2% to 6%, thevalues for this sample are high. It is argued that os acromialein this case may be related to long-term use of the very heavylongbows by the professional archers on the ship. The per-sistent use of this weapon, with its draw weight of about 57kg ( 125 lb), from a very early age was responsible for long-term shearing stresses on the acromion which inhibited fu-sion of the final element. The inflammatory nature of theunfused elements suggests the surfaces were subjected tosuch stresses in these cases (Figure 5).A defect in the rim of the acetabulum, usually in the pos-terior portion, has been called an acetabular flange lesion(Knowles 1983). In the absence of other serious pathology ofthe acetabulum or the femoral head its etiology is unclear. It has been suggested that it is produced by a "transient, in-complete, upward dislocation of the femoral head" (Knowles1983:65), which does not affect the femur. Eleven innomi- nates, four left and seven right, from this group are affectedby this lesion (Figure 6). Another suggestion offered is that itis a defect in the fusion of the pelvic elements (I. Watt 1986,pers. comm.). The appearance of these particular innomi- nates, however, where there is pitting of the affected rim,suggests a traumatic origin associated with activity but notserious enough to be permanently disabling.Enthesopathies are widespread in the burials from theMary Rose. These range from development of the linea as-pera, gluteal ridge, and hypotrochanteric fossa on the pos-terior femur (Figure 7) to lesions at the insertions of pec-toralis and teres major on the humerus and of biceps on theradius (Figure 8). There are many other examples and all arewidespread throughout the sample. Enthesopathies also oc-cur in the form of spurring, especially of the trochanters,calcaneus and , to a lesser extent , the olecranon process of the ulna. Some syndesmoses, particularly of the costoclavicularligament, show similar changes (Figure 9), with lesions andsome bony buildup. The exuberant nature of these changes,which far exceed those normally .seen in archeological mate- rial, must be explained in terms of processes. Zagreb Paleopalholony Symp. 19SH Diagnosis of occupationally related paleopathology ? 45 46 ? Ann Stirland Figure 8. Enthesopathies of humerus and radius (arrows). Figure 7. Development of linea aspera, gluteal ridge,and hypotrochantic fossa (arrows). Figure 9. Lesions of clavicular syndesmoses(arrows). Although such work is difficult, some contribution may bemade. In an archeological sample, it will never be possible toextrapolate from the general to the particular and assign anindividual's occupation from a group study. In a personalsense, I will never be able to say: "This man was an archer."What needs to be done, however, is to compare specificgroups. Such comparison must obviously be as rigorous as possible, so that groups from the same time period and/orgeographical area should be compared. What is needed issimilarity studies (Waldron 1987, pers. comm.). In this way,groups could be compared for similarities and differences.When all other factors, such as age, sex, and side, are equal,then differences, such as have been described for the MaryRose crew, can be related to a group activity or occupation. Zagreb Pateopiilbology Symp. IWH Diagnosis of occupational ly related paleopathology ? 47 With regard to the Mary Rose, a research program has beenundertaken which will implement such group studies. Otherlarge medieval groups from southern England will be com-pared with that sample and the differences will be evaluated.Perhaps then it will be possible to say with more confidencethat, all else being equal, the sample from the Mary Rose isdifferent and these differences are due to the occupationsfollowed by the crew. Literature cited Anderson, J.A.D. 1974. Occupation as a Modifying Factor in theDiagnosis and Treatment of Rheumatic Diseases. Current Medi-cal Research and Opinion, 2(9).1984. Arthrosis and its Relation to Work. ScandinavianJournal of Work Health. 10:429-433.Anderson. J.A.D. . and J. JR. Dulhie. 1963. Rheumatic Complaintsin Dockyard Workers. Annals of the Rheumatic Diseases,22:401-409.Bennett. G.E. 1959. Elbow and Shoulder Lesions of Baseball Play- ers. American Journal of Surgery. 98.Dutour. O. 1986. Enthesopathies (Lesions of Muscular insertions) as Indicators of the Activities of Neolithic Saharan Populations.American Journal of Physical Anthropology, 7 1 ;22 1 -224.Hadler. N.M. 1977. Industrial Rheumatology: Clinical Investiga-tions into the Influence of the Pattern of Usage on the Pattern ofRegional Musculoskeletal Disease. Arthritis and Rheumatism,20(4). 1980. The Variable of Usage in the Epidemiology of Os-teoarthrosis. In J.G. Peyron. ed., Epidemiology of Osteo- arthritis. Symposium Paris. Juin.Hadler, N.M.. D.B. Gillings. H.R. Imbus. P.M. Levitin. D.Makue. P.D. Utsinger. W.J. Yount. D. Slusser. and N.Moskovitz. 1978. Hand Structure and Function in an IndustrialSetting. Arthritis and Rheumatism. 21(2).Hagberg, M. 1984. Occupational Musculoskeletal Stress and Dis-orders of the Neck and Shoulder: A Review of PossiblePathophysiology. International Archives of Occupational andEnvironmentaJ Health. .53:269-278.Kaplan, PA., and D. Resnick. 1986. Stress-Induced Osteolysis ofthe Clavicle. Radiology 158:139-140.Kennedy. K.A.R. 1983. Morphological Variations in Ulnar Supina-tor Crests and Fossae as Identifying Markers of OccupationalStress. Journal of Forensic Sciences. 28:871-876.Knowles. A.K. 1983. Acute Traumatic Lesions. InG.D. Hart.ed.,Disease in Ancient Man. 65. Toronto: Clarke Irwin.Lawrence, J.S. 1955. Rheumatism in Coal Miners Part III: Occupa-tional Factors. British Journal of Industrial Medicine. 12:249-261.l.indbcrg, H.. and L.G. Danielsson. 1984. The Relation betweenLabor and Coxarthrosis. Clinical Orthopaedics and Related Re-search, 19(1). Lockshin, M.D., ITT. Higgins. M.W. Higgins. H.J. Dodge, andN. Canale. 1969. Rheumatism in Mining Communities in Mar-ion County, West Virginia. American Journal of Epidemiology,90( 1 ).Merbs. C.F. 1983. Patterns of Activity-Induced Pathology in aCanadian Inuit Population. Ottawa: National Museums ofCanada.Mintz. G, and A. Fraga. 1973. Severe Osteoarthritis of the Elbowin Foundry Workers. Archives of Environmental Health, 27:78-80.Ortner, D.J. 1968. Description and Classification of DegenerativeBone Changes in the Distal Joint Surfaces of the Humerus. Amer-ican Journal of Physical Anthropology, 28: 139-156.Radin. E.L.. I.L. Paul, and R.M. Rose. 1972. Hypothesis: Role ofMechanical Factors In the Pathogenesis of Primary Osteo- arthritis. Lancer, 1:519-521.Resnick. D.. andG. Niwayama. 1981. Diagnosis ofBone and JointDisorders, vol. 2. Philadelphia: W.B. Saunders.Rogers. J. T. Waldron, P. Dieppe, and I. Watt. 1987. Arthropathiesin Paleopathology: The Basis of Classification According toMost Probable Cause. Journal of Archeological Science.14:179-193.Rule, M. 1982. The Mary Ro-ie: The Excavation and Raising ofHenry VIlTs Flagship. Leicester, U.K.: Windward Press.1983. Henry Vlll's Lost Warship. National Geographic,163:646-675.Sairanen. E.. L. Brushaber, and M. Kaskinen. 1981 . Felling Work.Low Back Pain and Osteoarthritis. Scandinavian Journal of Workand Environmental Health. 7: 1 8-30.Stirland, A. 1987. A Possible Correlation between Os Acromialeand Occupation in the Burials from the Mary Rose. Proceedingsof the 5th European Meeting of the Paleopathology Association,327-334. Siena, Italy. 1984.Waldron. T. 1987. Osteoarthritis at Christ Church, Spitalfields: AnInterim Report. Paper presented at the 14th annual meeting of thePaleopathology Association, April 1-2. New York. Summary of audience discussion: Discussion quickly made itclear that the audience was divided on the question of whether thelesions demonstrated as osteochondritis dissecans were of meta-bolic, traumatic, or even developmental nature. Several felt theyhad seen similar lesions under circumstances making it reasonableto relate them to occupations resulting from prolonged and repeti-tive minor trauma such as a recent (19th century) military, young adult group under heavy stress. By law Renaissance youths initiatedlongbow training (which placed a 3(X)-pound pressure on eachshoulder) at age of six years. It is conceivable that application ofsuch stress to a growing bone may induce lesions to which a maturebone would be resistant. All agreed an investigational, radi-ologically based study on modern individuals with known, selectedoccupations could make a major contribution to the identification ofosteologic lesions useful for prediction of handedness and occupa-tions. Zagreb Paleopathology Symp. 1988 Methods Recovery of bone and serum proteinsfrom human skeletal tissue: IgG,osteonectin, and albumin Noreen Tuross The most common substrates from which to infer or deducevertebrate paleopathology are bones and teeth. Physical an-thropologists have explored the significant contribution thatmorphology and histology of mineralized tissues can make toour understanding of paleopathology. This study describesinformation at the molecular level that remains in the bonesand teeth of some of our ancestors.The presence of amino acids in fossil bones and teeth wasthe first evidence that proteins indigenous to the animalmight remain in the mineralized tissues (Abelson 1956; Ho1965). The preservation of the amino acids from the majorbone protein, collagen, was documented in a variety of fos- sil bones from many locations (Ho 1965; Wyckoff andDoberenz 1965; Tuross and Hare 1978). In fossil bones muchof the collagen exists as a heterogeneous mixture of degrada-tion products relative to the original gene product (Tuross et al. 1980). Isotopically. however, the degraded collagen isassumed to retain the pertinent information for archeometric use. Radiocarbon from collagen has been used to date fossils(Libby 1955; Taylor 1987) and the stable isotopes of carbonand nitrogen from bone collagen have been used in paleodic-tary interpretations (Schoeninger et al. 1983; Schoeningerand DeNiro 1984). Degradation of collagen, particularly the relative loss of the amino acid, glycine, can perturb the car-bon and nitrogen stable isotope values obtained from fossilbones and teeth (Tuross et al . 1 988 ). Better methods of isola-tion and characterization of proteins from fossil bones andteeth will contribute to the accuracy of archeometric isotopicapplications.Many proteins other than collagen can be found in modernbone. Both scrum-derived and bone-cell-produced proteinscan be extracted from bone. The complexity of the mixture ofproteins found in bone can be seen in a two-dimensional gelelectrophoresis analysis of bovine bone where approximately2(X) separate proteins were observed (Dclmas et al. 1984). Extraction techniques developed by John Termine andcoworkers allow for the mineral and nonmineral associatedproteins to be solubilized (Termine et al. 198 1 ). Five proteinsfrom the mineral compartment of developing human bonehave been purified and partially characterized (Fisher et al.1987).Of greatest potential interest to the paleopathologist is thepreservation of serum-derived proteins in bone. Two serumproteins, albumin and alpha-2-HS. concentrate in bone andmake up 13% of the noncollagenous bone matrix proteinsextracted from fetal human subperiosteal bone (Robey et al.1988). Smaller amounts of many other serum-derived pro-teins, including transferrin and the immunoglobulins (IgG,IgA, IgM and IgE). can be isolated from modern bone.Noncollagenous proteins, osteonectin, albumin. IgG, andtransferrin, have been identified at their original molecularweight in several individuals from the Windover archeologi- cal site in Florida. This 7000-year-old site, excavated underthe direction of Glen Doran, yielded in excess of 150 humanskeletons. The preservation of the mineralized tissue fromthe Windover site was variable. Generally, however, the neu-tral peat environment provided an anoxic, reducing atmo-sphere that was conducive to protein preservatit)n in thesebones.This study examines the preservation of noncollagenousproteins?osteonectin, IgG, and albumin? in protein ex-tracts from human skeletal material excavated at the Sullyand Mobridge sites in South Dakota. These cemeteries wereexcavated in the 1920s and the 1950s, and the collections reside in the National Museum of Natural History, Smithso-nian Institution. Associated materials al these sites date the skeletal remains at two to three hundred years of age. Theseskeletons are a classic museum collection, and provide theopportunity to assess the preservation of protein in bones thathave been disinterred for 30 to 50 years. Zagreb Paleopathology Symp. 1988 51 52 ? Noreen TurossPROTEIN EXTRACTS A. ir> h? 00lO m lOW CO COlO" lo" lo"cvj C\J CVJCO CO CO 111cE3 lo r^ 00lO lO lOCO^ CO co^lO" lO lO"C\J CVJ CMCO CO CO stained PartiallyDestainedCOOMASSIEFigure 1 . Protein extracts from three Mobridge site individ-uals on an SDS 4-20% polyacrylamide gel stained withCoomassie Brilliant Blue. Fully stained extracts are a smearof collagen degradation products over the entire molecularweight range of the gel. Equivalent extracts, partially de-stained in methanol/acetic acid/water, have discrete bandsapproximately 70 Ka and below. Multiple bands are apparentin each sample. Sharp, highly stained gashes above 97 Karegion are due to large amounts of protein (500 fig) applied totop of each lane. Materials and methods Thirteen rib fragments, weighing from 2 to 5 g, were takenfrom individuals (catalog numbers 325348, 325352-325358, 381159, 381163, 381193, 381342 and 381345,38 1 346) and extracted in 4M guanidine HC1/0.5M EDTA at4?C for two days. This procedure partially deriiineralized thesamples. The guanidine/EDTA was removed from the sol-uble protein by desalting 35 ml of the solution over a P6DGcolumn. The proteins were monitored at 254 nm, elutcd in100 mM ammonium acetate, and lyophilized.Fractions of the desalted protein were concentrated byCentricon (Amicon) filtration, and protein above 30,(X)0 mo-lecular weight retained on the filter was electrophoresed. Mini-gradient SDS gels. 4-20% acrylamide (Novex) wereused in a traditional Laemmli (Laemmli 1970) buffer system.The gels were stained with Coomassie Blue, and partiallydestained for up to four days.Bacterial collagcnase (Advanced Biofractures) digestionsof up to 1 mg of protein were done at 37?C for 4 to 8 hours.The fossil protein digests were then subjected to Centriconfiltration with a membrane that would retain all proteinsabove 10,000 molecular weight. The filters were extractedwith gel sample buffer and gel electrophoresed as describedabove.Electroblotting of collagenase digested proteins onto ni-trocellulose was performed according to the method of Tow-bin et al. (1979). Nitrocellulose electrotransfers were pro-cessed for immunodetection by using 1:1000 dilution of rabbit antihuman osteonectin and albumin (Cappel Laborato- ries) and a 1:2000 dilution of peroxidase conjugated goat antirabbit IgG (Kirkegaard and Perry Laboratories) and4-chloro- l-naphthol color reagent. IgG detection wasachieved with a 1:1000 dilution of rabbit antihuman perox-idase conjugated IgG (Capell Laboratories). Results and discussion The protein extracts from all bone samples were collagen-like in their amino acid pattern. Gel electrophoresis (Figure1) of the whole protein extract gave a smear of Coomassiestainable material that ranged in molecular weight from> 200,000 to the 30,000 retained on the Centricon filter.This collagen smear is common in electrophoresed fossilbone extracts (Tuross et al. 1980) and results from multiplepeptide bond breaks along the collagen molecule. Partialdestaining of these Coomassie stained gels revealed the pres-ence of bands of protein originally obscured in the fullystained gel (Figure 1 ).The fully stained fossil protein extracts and the equivalentpartially destained extracts are shown in relation to the pro-teins extracted by guanidine/EDTA in a modem human fetalcalvarium. In modem bone, collagen is largely insolublewhen subjected to the dissociative, demineralizing condi-tions of guanidine/EDTA (Termine 1983). In fossil bone,however, the partial breakdown of the collagen moleculerenders this protein soluble to the same dissociative de-mineralizing conditions.This increased solubility of the collagen degradation prod- ucts makes the isolation and characterization of any remain-ing intact noncollagenous proteins or native collagen moredifficult. Generally, large amounts of protein (up to 1 mg)from each skeletal sample must be applied to a gel in orderto visualize any "bandable" protein upon partial destainingof a gel. Applying a large amount of protein to a gel can leadto several type of distortions, including the short, sharp,gashlike disconformities seen at the top of several lines inFigure I . Zagnb Paleopathology Symp. 1988 Recovery of bone and serum proteins from human skeletal tissue ? 53 Allowing an electrophoresed total protein extract to par-tially destain after Coomassie Blue staining produced dis-crete bands of protein in 12 out of the 13 skeletal fragmentsanalyzed. The number and the molecular weight of thesebands varied among bone fragments, but generally, the mostcommon band observed was at approximately 68 Ka. Severalbands were also observed at 60 Ka, 45 Ka, and 42 Ka. The ability to see bands of protein as the collagen degradationproducts destain is due to the fact that collagen is a relativelypoor Coomassie binder. Therefore difi'erent bands could beobserved at varying stages of the destaining process, and anyprotein that binds Coomassie Blue equally or less well thancollagen would not be seen at all. Another problem with theextensive collagen degradation products is the interference intransferring the fossil protein to nitrocellulose paper for im-munological detection. Because a percentage of the proteinmoves from the gel to the paper with time, it is difficult totransfer enough of the putative intact protein in a reasonableamount of time.The total protein extracts were digested with bacterial col-lagenase. Bacterial collagenase is an enzyme that degradesany string of amino acids, Gly-X-Pro or Hypro, to tripep-tides. Since only collagen has repeats of Gly-X-Pro orHypro, this is the only protein that will be affected by thecollagenase treatment. All of the skeletal fragments pro-duced protein that was partially degradable by bacterial col-lagenase, and all digested fossil bone protein extracts ex-hibited at least one Coomassie stainable band uponpostdigestion electrophoresis (Figure 2).The ability to digest the background smear on the gels withbacterial collagenase is proof that the staining was caused bycollagen breakdown products. The existence of Coomassiestainable bands after collagenase treatment is proof of thepreservation of several noncollagenous proteins in these fos- sil bones.While preliminary identification of these bands can bemade based on their molecular weight, immunological iden-tification by reacting the transferred bands to purified anti-bodies is the basic criterion upon which protein identificationshould be made. This immunodetection technique (com-monly called Western blotting) requires that one and only oneband at the appropriate molecular weight recognize the anti-body being used.In preliminary analysis of the collagenase digested elec-trotransfers, the proteins albumin, osteonectin, and IgG wereidentified from these skeletal remains. Albumin was by farthe most prevalent among the preserved noncollagenous pro-teins in the samples. The identification of IgG in some of thecollagenase extracts demonstrates the ability to detect intactproteins from fossil extracts even in the absence of a clearCoomassie stained band on the gel.The demonstration of preservation of noncollagenous pro-teins in fossil bones that have been washed, treated andstored in a museum collection is an important addition to the COLLAGENASE B. oic?X lO r^ 00lO lO lOCO CO COlo" in lo"CVJ C\J CMCO CO CO200K 1^1 54 ? Noreen Tuross Literature cited Abelson. PH. 1956. Paleobiochemistry. Scienlific American.195:83-92.Delmas. P.D., R.P. Tracy. B.L. Riggs, and K.G. Mann. 1984.Identitlcation of Noncoliagenous Proteins of Bovine Bone byTwo-Dimcnsional Gel Electrophoresis. Calcified Tisstw Inicnui-tional, 36:308-316.Fisher, L.W., G.R. Hawkins, N. Tuross, and J.D. Termine. 1987.Purification and Partial Characterization of Small Proteoglycans I and II. Bone Sialoprotcins I and II. and Osteonectin from theMineral Compartment of Developing Human Bone. Journal ofBiological Chemislry: 262:9702-9708.Ho, T. Y. 1965. Amino Acid Composition of Bone and Tooth Pro-teins in Late Pleistocene Mammals. Proceedings of the NationalAcademy of Science, 54:26-31.Laemmli. U.K. 1970. Cleavage of Structural Proteins during theAssembly of the Head of Bacteriophage T4. Nature. 227:680-685.Libby, W. 1955. Radiocarbon Dating. 2d edition. Chicago: Univer- sity of Chicago Press.Robcy. P.G.. L.W. Fisher, M.F. Young, and J.D. Termine. 1988.The Biochemistry of Bone. In B.L. Riggs and L.J. Melton, eds..Osteoporosis: Etiology. Diagnosis and Management, 95-109.New York: Raven Press.Schoeninger, M.J., and M.J. DeNiro. 1984. Nitrogen and CarbonIsotopic Composition of Bone Collagen from Marine and Ter- restrial Animals. Geochimica et Cosmochimica Acta. 48:625-639.Schoeninger, M.J., M.J. DeNiro, and H. Tauber. 1983. Stable Ni-trogen Isotope Ratios of Bone Collagen Reflect Marine and Ter- restrial Components of Prehistoric Human Diet. Scieiwe.220:1381-1383.Taylor, R.E. 1987. Radiocarbon Dating: An Archaeological Per-spective. Orlando, Fla.: Academic Press.Termine, J.D. 1983. Osteonectin and Other Newly Described Pro-teins of Developing Bone. In W.A. Peck., ed.. Bone and MineralResearch, 144-156. Amsterdam: Excerpta Medica.Termine, J.D., A.B. Belcourt. KM. Conn, and H.K. Klcinman.1981 . Mineral and Collagen-Binding Proteinsof Fetal Calf Bone.Journal of Biological Chemistry. 256(20): 10403- 10408.Towbin, H., T. Staehilin, and J. Gordon. 1979. ElectrophoreticTransfer of Proteins from Polyacrylamide Gel to NitrocelluloseSheets: Procedure and Some Applications. Proceedings of theNational Academy of Science, 76:4350-4354. Tuross, N.. D.R. Eyre, M.E. Holtrop, M.J. Glimcher. and P.E.Hare. 1980. Collagen in Fossil Bones. In P.E. Hare, ed.. Bio-geochemistry of Amino Acids, 53-63. New York: Wiley andSons.Tuross, N., M. Fogel. and P.E. Hare. 1988. Variability in the Pres-ervation of the Isotopic Composition of Collagen from FossilBone. Geochimica et Cosmochimica Acta, 52:929-935.Tuross, N., and P.E. Hare. 1978. Collagen in Fossil Bone. Car-negie Institution of Washington Yearbook. 77:891.Wyckoff. R.W.G., and A.R. Doberenz. 1965. Electron Microsco-py of Rancho La Brea Bone. Proceedings ofthe National Acade-my of Science. 53:230-233. Summary of audience discussion: The ability to identify in ar-cheological human remains the serum antibodies present at the timeof death would provide access to an incredibly valuable legacy ofthe history of specific infectious diseases suffered by an ancientpopulation. However, it must be emphasized that demonstration ofthe presence of a major molecular IgG fraction does not guaranteethat the variable end of the light chain is preserved well enough toreveal its immunologic specificity, which is necessary for identi-fication of the specific infectious agent against which the antibody isdirected. Unfortunately the next analytical step in pursuit of thatgoal involves the use of chemicals strong enough by themselves to alter even the preserved protein. Recent studies on an excavated,150-year-old seaman of the mid- 19th century Franklin expedition,buried deep in North American arctic permafrost, demonstrated theresearch potential of cryopreserved bodies, but the surface arcticsummer thawing conditions frustrate such efforts in most instances.Ancient tissues usually contain a host of polypeptides secondary topartially degraded protein, and the potential of these to react withimmunological diagnostic reagents is untested. For this reason itappears desirable to include more controls than usual when applyingsuch immunodiagnostic methods to archeological remains, and tobe meticulously cautious in interpretation of their results. Investiga-tions leading to diagnostic security in the use of Immunologicalmethods would be a major contribution to paleopathology. A recentOxford conference presentation suggested the presence of proteinwithin the hydroxyapatite crystals of fossil bone. The potentialvalue of recovering intact protein there justifies serious researchpursuit of that observation. Ziinnh Palenpalhology Symp 1988 Bone histology and paleopathology:Methodological considerations Debra L. Martin In the last hundred years, identification and analysis of dis-ease processes have dramatically increased in the area ofpaleopathology. However, prior to the last ten years, analysishad remained primarily descriptive with the aim to identifydisease in space and time. Recent emphasis on the interac-tions between biology and culture in the disease process hasproven to be fruitful, yielding information concerning humanadaptability within an evolutionary framework. A furtherexpansion of the biocultural approach involves using skeletalmaterial as an aid in elucidating processes and bone bio-dynamics in health and disease states.Given the interest in skeletal growth, pathology, mainte-nance, and repair, analyses should ideally proceed in a logi- cal and complementary fashion from the gross and mac-roscopic analysis to the histological and microscopic level.Building on this data base, the biochemical and molecularassays can follow. In this manner, identification of patholog-ic conditions, patterns of growth and development, changesin gross morphology, and alterations in the rate of morbidityand mortality can form the contextual framework for theother types of analyses. While emphasis on gross mor-phological features and measurements remains important tothe reconstruction of human paleobiology and populationsuccess in adjusting to the physical environment, evidencenow exists that other skeletal parameters (such as histology)can offer valuable information on health status prior to death(Martin etal. 1985).Bone at the microscopic level can be used as a tool, that is,as a model system or biological "window" into the past giv-ing a view of earlier behavior and health of the skeletal sys-tem (Frost 1964). The objectives of paleohistological analy-ses are to assess bone remodeling activity for entirepopulations and to examine the association of remodelingwith age, sex, stature, pathological conditions, and cultural affiliation. The bridging of macroscopic data with micro-scopic data is seen as an essential step toward addressingdifferential health status across age, sex and culture. Tech-niques used by anthropologists must be based on biomedical precedents which are most applicable to archeological speci-mens. These techniques should include measure of bonequantity (cortical thickness, cortical area, and rate of re-modeling) and hone quality (quantification of the size, dis-tribution, and level of mineralization of discrete units ofbone). These measures need to be based on well-defined skeletal parameters which are accurate, replicable. and use-ful in comparative analyses.Examplesofthetypesof multidimensional analyses which utilize histology include assessment of male and female dif-ferences in bone maintenance, correlation of macroscopicfeatures of bone with microscopic features such as growth arrest, identification of subgroups at risk with respect toproblems in bone metabolism, the effect of changing levelsof sociopolitical organization and nutrition on health, and the effects of agricultural intensification on growth and develop-ment.Given what is currently known concerning the relationshipbetween structural and physiological functions of bone, opti-mal conditions for normal growth and development can behypothesized. These optimal conditions include adequate nutrition, low disease stress, proper endocrinological func-tion, and normal age-related wear and tear on the skeletalsystem. If these conditions are not met, the degree of dys-function which results will parallel the seriousness and dura-tion of the stressing agent (Ortner 1976). Analysis of health atthe microstructural level can help define not only the exis-tence, but al.so the severity, of stress in individuals with al-tered physiological states. Health information gained in thisway can be assessed in conjunction with information fromother areas, such as the archeological data. The comprehen-siveness of the data will allow interpretations about the bio-logical evidence of health, the archeological reconstructionof ecological and cultural variables, and the demographicprofiles resulting from accumulated morbidity and mortality at the population level.Loss of bone (osteopenia) and lack of bone mineralization(osteoporosis) arc the two most important responses that Zagreb Ptileopalhology Symp. I9SS 55 56 ? Debra L. Martin skeletal tissue makes when under physiological stress. Grosspathologic changes on bone reveal insults to which an indi-vidual may have been subjected such as infectious disease,trauma, and degenerative changes such as arthritis. Tradi-tionally, the health status of prehistoric individuals was basedon these gross indicators alone. The analysis of bone his-tology provides information on a more subtle level ? information concerning chronic or episodic undernutrition,periods of physiological disruption which leave no trace onthe outer skeletal surfaces, the long-term effects of multi-parity and lactation on female calcium metabolism, and the effects of immobilization on skeletal health.In summary, analysis of physiological aspects of skeletalremodeling provides a clue to an individual's lifestyle, diet,reproductive activity, and nutritional adequacy. These in-dicators of health are rarely "clinically" significant; they re-flect the day-to-day physiological responses which individu- als must make. It is these responses at the histological levelon which current research can focus. Bone biodynamicsA general familiarity of normal bone histology, as well as thenormal processes involved with growth, development, main-tenance and repair, is necessary in order to highlight andunderstand the range of possible responses bone can makewhen experiencing physiological stress. Bone is a highlyspecialized kind of connective tissue and it is distinguishedfrom other tissues such as skin and cartilage by its hard and crystalline structure. Bone has a cellular matrix composed ofcollagen and protein fibers embedded in a ground substancehigh in mucopolysaccharides. The hardness of bone comesfrom crystalline salts of calcium, phosphate, and carbonatedeposited within the organic matrix. Specialized cells medi- ate the deposition and withdrawal of the mineral componentof bone to keep an even balance between the body fluids andthe skeletal reserves (Raisz and Kream 1983). Bone exists ina dynamic equilibrium with blood, and the "bone-body con-tinuum" is regulated by nutrients and hormones (McLean andUrist 1968).Much of the outward appearance, and most of the histo-logical aspects of bone reflects the biological responses tophysical and structural requirements. The diverse set of func-tions which a skeletal system provides (for example, struc-tural support, locomotion, storage and regulation of miner- als, control of ionic concentrations in body fluids, andproduction of red blood cells) necessitates a high priority formaintenance. Thus, as a connective tissue, bone is an openand living system which changes constantly throughout lifeto meet the demands for growth, development, maintenanceand repair.Disturbance in normal patterns of growth, mineralization,and remodeling form the pathogenesis of nutritional, hormo- nal, disease and aging problems (Jowscy 1964). These pro-cesses can be measured, and the values can be used to define boundaries between health and disease. Quantification ofhistological properties of bone aids in making diagnoses andindicates the probabilities that the properties of an individualcase are within healthy or diseased states (Byers 1977).Osteons are discrete units of bone which are the majorquantifiable histological features used in diagnostic analy- ses. In the femur, osteons measure approximately 0.25 mmin diameter and are easily viewed under low or high magni-fication. Osteons take a variable length of time to form. In aten-year-old individual osteons take 46 days to attain com-pleteness and full mineralization. In a 60-year-old, osteonscan take as long as 108 days to attain completeness (Lips et al. 1978).Both complete osteons and partial osteon fragments re-main visible for many years, since at any given time only 3-5% of the skeleton of an individual undergoes active re-modeling during adulthood (Frost 1964). Osteons, resorptionspaces, fragments, and layers of bone without osteons(lamellae) play a central and critical role in maintaining thequality and quantity of bone.Once bone has been shaped by growth, it can be altered bythe remodeling process, or "turnover" of bone (Frost 1973).There is activity of some degree in every part of the skeletonthroughout life. The two basic components of this process areformation of osteons and resorption of older osteons. Re-modeling is the resorption of older units of bone and forma-tion of and replacement with newly mineralized bone. Re-modeling can be viewed as quantitative changes in osteonal size, degree of mineralization, and placement within the cor-tex of bone.Resorption and formation are not independent phenome- na; they are coupled. After each resorption activity, there isalways a formation activity although the rate is variable. Thecycle of resorption and subsequent formation can take fromthree months to one year (Frost 1969). The formation/resorption ratio is a relative indicator of how many cycles arein progress, but does not indicate at what point the cycles are,or if the cycles are proceeding normally.Although remodeling continues at predictably different rates in each decade of life, the consequence is an ever-increasing population of osteons per unit volume of corticalbone. Remodeling occurs slowly enough that previously re-modeled bone remains unchanged for long periods of time.The actual rate of remodeling can be measured by comparingthe number of older bone units with that of newer bone (Frostand Villanueva 1960; Jowsey 1964) or by determining theamount of bone laid down over the course of the life span(Frost and Wu 1967).A healthy individual weighing 72 kg has approximately 14kg of skeletal tissue. Of that 14kgofbone, half is composedof calcium (Posncr 1979). Calcium is extremely important tothe biochemical constitution of skeletal tissue. Approxi-mately 99% of the calcium ingested from food goes directlyto the skeletal tissue; only 1% of the calcium remains cir-culating in the blood (Raisz 1977). The small percentage of Zagreb Paleopalholdity Symp. I91IH Bone histology and paleopathology: Methodological considerations ? 57 calcium in the circulatory system is crucial for the mainte-nance of cardiac and nervous system function (Marshall et al.1976).In summary, diet, disease, and aging are all factors which affect calcium metabolism and bone remodeling, and these are especially valuable variables to track in prehistoric skele-tal populations. This brief summary of bone dynamics servesto highlight the complexity of bone as a tissue and, moreimportantly, to suggest the ways in which the .skeletal systemresponds to physiological disruption and the ways that thisresponse can be reconstructed from the histological proper-ties. Skeletal remodeling provides a measure of skeletalhealth as well as an indication of the health of the individualas a whole. Of particular mterest to this research is thatskeletal remodeling presents an ideal form of evidence lead-ing to an understanding of prehistoric health. By understand-ing the physiological properties of skeletal remodeling, aclearer and more realistic reconstruction of past health can bemade. Response to stress on a histological level Bone tissue is most affected by three factors: aging, disease,and nutrition (Smogyi and Kodicek 1969). Of particular sig-nificance to anthropological research is the fact that bonemicrostructure is sensitive to these factors, and tissue at themicrostructural level is frequently preserved in archeologicalspecimens (Stout 1978).Bone reacts to stress in a limited number of ways. Ingeneral, the skeletal response to physiological stress is one(or a combination) of three phenomena: ( 1 ) reduced bonemass, (2) increased bone mass, and (3) poorly mineralized orabnormal bone quality (Meunieretal. 1979). It is the type ofresponse, the timing of onset, the degree of severity, thepattern, and the frequency of abnormal histological proper-ties which aid in the interpretation of remodeling. It is a well-documented fact that structural and physicalresponses of bone to biological needs are affected by theaging process (Kerley 1965). A knowledge of normal, age- related processes in bone represents a factor critical to theunderstanding of pathological or abnormal conditions. Oneimportant distinction to be able to make when dealing withbone loss is the one between loss due to old age and loss dueto other factors such as disease, malnutrition, or hormonalimbalances. Clinical methods for delineating bone loss as afunction of age and other factors are outlined in Barzel(1979), Fro.st (1973), Jaworski (1973), and Simmons andKunin(l979).Skeletal remodeling can also be significantly altered byinsufficient nutrients. Theeffectsof nutrient deficiencies canbe compounded not only by inadequacies in the diet, but byfurther problems in malabsorption of nutrients in the system.Experimental studies on animal models have shown the effects of protein-caloric malnutrition to be systemic andgeneralized (Steward 1975). During protein-calorie mal-Zagnb Paieopalhotogy Symp. 1988 nutrition growth slows or ceases, remodeling rates increase,and removal of bone exceeds deposition with mineralizationof existing bone greatly slowed (Dickerson and McCance1961).Studies conducted on clinical populations experiencing nutritional stress support the findings that a general sequenceof events are followed. These include ( 1 ) retardation in longbone growth and delayed maturation for children, (2) slowedformation of new bone for adults and children, and (3) exist-ing bone loss by resorption with a net decrease in bone mass(Gam 1970).While bone loss can be viewed as a pathological condition, it is important to note that the loss can also be seen as anadaptive response under certain circumstances such as nutri-tional stress. In the face of protein-calorie malnutrition ordeficiencies in minerals, skeletal reserves can be used forgrowth, repair or function.Rather than searching for a single diagnostic criterion,patterns of bone growth and maintenance must be examinedwith the emphasis on stress markers at the different stages of skeletal activity throughout the life cycle. Remodeling ac-tivities need to be carefully examined in conjunction withother variables such as age, sex, and pathologic conditions inorder to interpret the nature and severity of nutritional stress. Use of histology in anthropological researchAs early as 1 849, researchers were looking at microstructureof fossils, and in 1878 an extensive histological analysis offossil bone and teeth demonstrated that histological struc-tures were preserved in archeological specimens (Stout andSimmons 1979). Advances in technology led to a furtherunderstanding of the extent to which skeletal histology ispreserved. Archeological specimens of varying age and fromdiffering soil types and differing degrees of moisture ex-posure have been compared at the histological level for pres-ervation. Race and co-workers (1968) found that the greatest alteration in skeletal material due to weathering was chemi- cal in nature (not structural), and that osteons were often visible even in samples where severe chemical diagenesishad occurred.During the early 1900s, attempts to detect abnormalities inpreserved skeletons increased along with the methods used toassess pathological conditions (Brothwell and Sandison1967). The development of radiographic techniques and theapplication to prehistoric specimens by Moodie (1923) madesubstantial progress in paleopathological research. Moodie 'swork often used histological sections, although analysis ofthe sections was not based on quantifiable measures. In spiteof these early ob.servations of morphology, no systematicanalysis of histological structures was performed. Putschar stated, "one should not. however, expect too much help fromthe microscopic examination . . . since diagnostic micro-scopic bone patterns arc rare" and he further emphasized that "gross examination of the surface is more important" 58 ? Debra L. Martin (1966:58-59). This lament has perhaps inhibited the growthof histological studies on prehistoric skeletal material, butthe overwhelming success of more recent studies should putthat attitude to rest.Numerous methods have been developed to evaluate theabsolute amount of bone present. One noninvasive techniqueused is photon absorptiometry. Perzigian (1973) used thistechnique to test the hypothesis that change in diet affectedthe rate of bone loss. Greater bone loss was found to occur inthe agricultural group than in the gathering and huntinggroups in an archeological population from Indian Knoll.Stout and Teitelbaum ( 1976) offer one of the first detailedmethodological considerations on both how to prepare andhow to analyze a prehistoric thin section of bone. Practicalinformation concerning embedding, staining, and mountingsections is reviewed. The authors suggest numerous avenuesof potential research for the use of bone in the assessment ofhealth and disease. Ortner (1976) also presents a review ofthe potential application of bone histology to ancient skeletalremains. This study emphasizes the ability of histologicalproperties to give an indication of the aging process, nutri-tional adequacy, and disease status of prehistoric individuals.Martin and co-workers (1985) present a thorough review ofthe anthropological literature on methods for assessing quali-ty and quantity of diet through the use of histological analy- sis.An analysis of skeletal remodeling activity was under-taken for two Illinois Woodland populations representing the shift from intensive, harvest-collecting subsistence to that ofcom agriculture (Stout 1976). Thin sections of rib were usedand turnover rates were calculated, based on the density ofremodeled osteons, to estimate actual amounts of bone for-mation per year in square millimeters for each individual.The results indicated a tendency toward increased bone re-modeling rates in the agricultural population. The authorsuggested several possibilities for this, with dietary inade-quacies serving to explain the findings best.Patterns of remodeling have also been determined frommicroradiographs of femoral cross-sections. Martin and Ar-melagos (1979) combined cortical thickness and area mea-surements with histological analysis of osteons to examinebone loss and maintenance for an adult population from pre-historic Sudanese Nubia. Nubian females exhibit early anddramatic rates of bone loss on the organ level. Analysis of thedistribution of osteons and the rate of ostconal remodelingfurther showed the differences between age-matched malesand females. A diet low in calcium, iron, and protein, com-bined with endemic parasitic infestations, and the increasedmetabolic demands of reproduction created a negative skele-tal balance for young adult Nubian females (Martin and Ar-melagos 1985).Weinstein and co-workers ( 1 98 1 ) studied the histology of aPeruvian mummy and found that the histomorphometricswere profoundly dissimilar from normal parameters. The researchers concluded that an imbalance between bone for-mation and resorption was the result of a dietary stress.Thompson and Gunness-Hey (1981) used microstructuralanalysis to examine bone loss in Kodiak Island Eskimo popu-lations. Pfeifter (1981) and Pfeifter and King (1981) usedosteon counts of prehistoric Canadian populations to analyzeage structure and health.Richman and co-workers ( 1979) looked at osteonal varia-tions in Eskimo, Pueblo, and Ankara prehistoric popula-tions. They were able to document a significant increase inthe number of growth-arrested osteons in the Eskimos, and adietary explanation was postulated.In summary, the systemic and general nature of human skeletal response to stress has been profitably used on pre-historic remains to interpret the nature of the stressing agen-cies involved via examination of patterns of bone growth,remodeling, repair, and loss. The occurrence of physiologi- cal disruptions at different parts of the life cycle can be exam-ined and compared to the mortality rates of the group. Infor-mation from indirect and direct examination of skeletalremains has been combined with environmental data to pro-vide a more realistic reconstruction of the nutritional andhealth status of prehistoric groups. Conclusions In this brief and select overview of the anthropological usesof bone histology, there is ample evidence suggesting thatanalysis of bone histology can reveal information which farsurpasses information obtained from macroscopic analysesonly. Aging, disease, and nutritional stress are the maincategories which can be tracked using histological analysis.Given that these categories are precisely those used to recon- struct the health dynamics of prehistoric peoples, it seemstimely for histology to enter the mainstream of skeletal analy- ses in anthropology. For archeological populations, the as-pect of nutritional and disease stress in endemic or epidemicconditions holds the most potential for interpreting pre-historic adaptation.The use of histological analysis can highlight individualswho are experiencing health problems but who do not showgross pathologic changes. Further, subgroups within the pop-ulation can be identified who are most sensitive to stresseswhich affect skeletal health, and by extension, stresses which affect overall patterns of morbidity and mortality. Literature cited Barzcl, U.S.. ed. 1979. Osteoporosis II. New York: Grune andStratton.Brothwell, D.. and A.T. Sandison. 1967. Diseases in Antiquity.Springfield. III.: Charles C Thomas.Bycrs. P.D. 1977. The Diagnostic Value of Bone Biopsies. In L.V.Avioli and S.M. Krane. eds., Metuholic bone Disorders, 183- Zagreb Paleopaihology Symp. 1988 Bone histology and paleopathology: Methodological considerations ? 59 236. New York: Academic Press.Dickerson. J.W.T.. and R.A. McCance. 1961. Severe Undernutri-tion in Growing and Adult Animals: 8. The Dimensions andChemistry of the Long Bones. British Journal of Nutrition.15:567-576.Frost. H.M. 1964. Dynamics of Bone Remodeling. In H.M. Frost, cd.. Bone Biodynamics. 315-334. Springfield. 111.: Charles CThomas.1969. Tetracycline Based Histological Analysis of BoneRemodeling. Calcified Tissue Research. 3:211-237. 1 973 . Bone Remodeling and its Relation to Metabolic BoneDisease. Springfield. III.: Charles C Thomas.Frost. H.M., and A.R. Villanueva. 1960. Measurement of Os-teoblastic Activity in Diaphyseal Bone. Stain Technology,35:179-189.Frost. H.M.,andK. Wu. 1967. Histological Measurements of BoneFormation Rates in Contemporary Archaeological and Paleon-tological Compact Bone, in W.D. Woode. ed.. MiscellaneousPapers in Paleopathology. 9-22. Flagstaff: Museum of NorthernArizona.Garn , S .M . 1 970. The Early Gain and Later Loss ofBone in Nutri-tional Perspective. Springfield. 111.: Charles C Thomas.Jaworski. Z.F.G.. ed. 1973. Proceedings of the First Workshop onBone Morphometry. Ottawa: Ottawa Press.Jowsey. J. 1964. Variations in Bone Mineral with Age and Disease.Mechanisms of Hard Tissue Destruction. American As.sociationfor the Advancement of Science Publication, 75:447-470.Kcrley. E.R. 1965. The Microscopic Determination of Age in Hu-man Bone. American Journal ofPhysical Anthropology. 23: 149-163.Lips. P.. P.J. Munier. and P. Courpron. 1978. Mean Wall Thicknessof Trabecular Bone Packets in the Human Iliac Crest: Changeswith Age. Calcified Tissue Research. 26:13-17.Marshall. D.H.. B.E.C. Noirdin. and R. Speed. 1976. Calcium.Phosphorus, and Magnesium Requirements. Proceedings of theNutrition Society. 35 : 1 63- 1 73 . Martin, D.L.,andG.J. Armelagos. 1979. Morphometries of Com-pact Bone: An Example from Sudanese Nubia. American JournalofPhysicid Anthropology. 5 1 :57 1 -578.1985. Skeletal Remodeling and Mineralization as Indica-tors of Health: An Example from Prehistoric Sudanese Nubia.Journal of Human Evolution. 14:527-537.Martin, D.L., AH. Goodman, and G.J. Armelagos. 1985. SkeletalPathologies as Indicators of Quality and Quantity of Diet. In J.Mielke and R. Gilbert, eds.. The Analysis of Prehistoric Diets.227-279. New York: Academic Press.McLean, F.C., and M.R. Urist. 1968. Bone: Fundamentals of thePhysiology of Skeletal Tissue. Chicago: University of ChicagoPress.Meunier. P.J., P. Courpron, J.M. Geroux, C. Eduoard, J. Bernard,and G. Vignon. 1979. Bone Histomorphometry as Applied toResearch in Osteoporosis and to the Diagnosis of Hyper-osteoidosis States. Calcified Tissue Research (supplement),21:354-360.Moodie, R.L. 1923. Paleopathology. Urbana: University of IllinoisPress.Ortncr. D.J. 1976. Microscopic and Molecular Biology of HumanCompact Bone: An Anthropological Perspective. Yearbook ofPhysical Anthropology, 20:35-44. Perzigian. A.J. 1973. The Antiquity of Age-Assoeiated Bone Lossin Man. Journal of American Geriatric Society. 21:100-105.Pfeiffer, S. 198 1 . Bone Remodeling Age Estimates Compared withEstimates by Other Techniques. Current Anthropology. 21:793-794.Pfeiffer. S.. and P. King. 1981 . Intracortical Bone Remodeling andDecrease in Cortical Mass Among Prehistoric Amerindians.American Journal of Physical Anthropology. 54:262.Posner, A. 1979. The Relationship Between Diet and Bone MineralUltraStructure Federal Proceedings. 26:7717-1722.Putschar, W.G.J. 1966. Problems in the Pathology and Paleopathol-ogy of Bone. In S. Jarcho, ed.. Human Paleopathology. 57-65.New Haven, Conn.: Yale University Press.Race, G.J., E.L Fry, J.L. Mathews, H. Martin, and J. A. Lyon.1968. The Characteristics of Ancient Nubian Bone by CollagenContent and Light and Electron Microscopic Examination. Clini-cal Pathology. 45:704-713.Raisz, L.G. 1977. Bone Metabolism and Calcium Regulation. InA. Avioli and D. Krane, eds.. Metabolic Bone Disorders, llli-230. New York: Grune and Stratton.Raisz, L.G. , and B.E. Kream. 1983. Regulation of Bone Formation(XanAW). New England Jounuil ofMedicine. 2,m:29-l>5.%'i-?,9.Richman, G.A., D.J. Ortner, and F.P. Schulter-Ellis. 1979. Differ-ences in Intracortical Bone Remodeling in Three AboriginalAmerican Populations: Possible Dietary Factors. CalcifiedTi.ssue Research. 28:209-214.Simmons, D.J., and A.S. Kunin. 1979. Skeletal Research. NewYork: Academic Press.Smogyi, J.C, and E. Kodicek, eds. 1969. Nutritional Aspects ofthe Development of Bone and Connective Tissue. Series of theInstitute ofNutrition Research. 13.Steward, R.J.C. 1975. Bone Pathology in Experimental Malnutri-tion. World Review of Nutrition and Dietetics. 21:1-74.Stout. S.D. 1976. Histomorphomctric Analysis of ArchaeologicalBone. Ph.D. dissertation. Department of Anthropology. Wash-ington University. St. Louis.1978. Histological Structure and its Preservation in An- cient Bone. Current Anthropology. 19:601-604. Stout, S.D.,and D.J. Simmons. 1979. Use of Histology in Ancient BoneResearch. Yearbook of Physical Anthropology, 22:228-249.Stout, S.D., and S.L. Teitelbaum. 1976. Histological Analysis ofUndecalcified Thin Sections of Archaeological Bone. AmericanJournal of Physical Anthropology. 44:263-270.Thompson, D.D., and M. Gunness-Hey. 1981. Bone Mineral Os-teon Analysis of Yupik-lnupiaq Skeletons. American Journal ofPhysical Anthropology. 55: 1 -7.Weinstein, R.S., D.S. Simmons, andC.O. Lovejoy. 1981. AncientBone Disease in a Peruvian Mummy Revealed by QuantitativeSkeletal Histomorphometry. American Journal of Physical An-thropology. 54:321-326. Summary of audience discussion: In response to the question ofthe role of estrogen in bone remodeling, it was suggested that thehormone has a stimulating effect on endosteal osteoblasts and thatgrand multiparas tend to have thicker bones, although prolongedlactation may deplete bone mineral content. Zagreb Paleopathology Symp. I98ii 8000-year-old brain tissue from the Windover site: Anatomical, cellular, andmolecular analysis William W. Hauswirth, Cynthia D. Dickel, Glen H. Doran, Philip J. Laipis,and David N. Dickel The Windover site (8BR46) consists of a small (5400 m^)peat deposit in a low-lying swale on the western edge of theFlorida Atlantic Coastal Ridge, roughly equidistant from theIndian River coastal lagoon system and St. John's River ineastern, central Florida (Figure 1). Information from pre-liminary analysis of flora and fauna indicates the site was awooded marsh from 8000 b.p. to 6900 b.p. and during thistime was regularly used as a burial ground. Most bodiesfound at the site had been placed in a flexed position and thenburied lying on their sides in anaerobic, water-saturated peat at an approximate depth of one meter.The Windover site is a significant North American archeo-logical site for several reasons: it is one of the oldest Ameri-can sites with a large, representative human skeletal sample; it contains all age morphs; it has a large sample of prehistoricflexible fabrics; it has 91 crania containing preserved matteridentifiable as brain tissue; and intracranial tissue was dem-onstrated to be human by cellular and biochemical tech-niques and by isolation of human DNA (Doran et al. 1986). Results RADIOCARBON DATES During excavation four distinct types of peat strata wereidentified (Figure 2). The upper stratum (1.2 m thick) wascomposed of black sawgrass-peat (W. Spackman, Jr., andS.Stout, pcrs. comm. 1986). The lower levels of this black peatwere dated at 4790? 100 b.p. (Beta- 10763). Underlying theblack peat was a 1 .2-m-thick stratum of red-brown peat con-taining a high concentration of naturally deposited wood.The upper zone of this red-brown peat has been radiocarbondated at 5800?80 b.p. (Beta- 10764). The red-brown peat stratum had a striking preservation of intact leaves, sawgrassstrands, twigs, branches, turtle bones, fish remains, nonhu-man fecal material and other faunal material. The highestconcentration of skeletal material was within the lowest lev- els of the red-brown peat stratum. Underlying the red-brownpeat was an approximately 0.5-m-thick layer of "rubber"peat. The top of the rubber peat stratum has been radiocarbondated at 7950 ? 140 b.p. (Beta- 10855). Human and nonhu-man skeletal material and preserved wood decreased withincreasing depth of the rubber peat. The incidence of fresh-water moUusks was high in the rubber peat and may haveinfluenced the water chemistry of the pond. Beneath therubber peat was a I.8-m-thick stratum of tan-brown peat xlx MAX. DEPTHPOND WATER BLACK PEAT(SAWGRASS PEAT) RED BROWN PEAT(UPPER ZONE) RED BROWN PEAT(LOWER 70NF1 RliBBIR" PEAT TAN-BLACK PEAT(WATER-LILY PEAT) Analysis of 8000-year-old brain tissue from the Windover site ? 61 RADIOCARBON DATES 4790 ? 100 B. P. 5800 -t 80 B. P. 7360 ? 70 B. P. tinmanbone conccniralion 7950 ? 140 B.P 10, 160 ?: 120 B.P Table L Culturally relevant radiocarbon dates Dat^ Sample Laboratorynumber 6980 ?90 Wooden stake Beta-193167050 ?80 Peat near highest bone Beta-141326990 ? 70 Human bone (AMS) TO-2077100 ?100 Wooden stake Beta-193157210 ?80 Human bone Beta-71867290 ? 120 Bottle gourd Beta-204507300 ?70 Wooden stake Beta- 197227330 ? 100 Human bone Beta-58037360?70 Peat beneath crania Beta-113817410 ?80 Peat from brain surface Bela-113837830 + 80 Human bone (AMS) TO-5187930 + 80 Wooden stake Beta- 182958120 ? 70 Human bone (AMS) TO-2418430 + 100 Peat at base of Beta- 13909red-brown strata a. Date in radiocarbon years B.P. GREY SAND maximum depth of grey sand not determined Figure 2. Stratigraphic profile, peat types, and uncorrectedradiocarbon dates on peat from the Windover site, 8BR246.Radiocarbon dating either by Isotrace Laboratory, Universityof Toronto, Canada, or by Beta Analytical, Coral Gables,Florida. Sample numbers indicated in text (e.g.. Beta10763). Dates in years b.p. Correction factor of +800 yrB. p.should be added to dates between 7000 and 10,000 yr b.p.(Klein et al. 1982). MAMASL. meters above mean annual sealevel. Vertical scale units, 20 cm. containing no freshwater mollusks or human bone. This stra-tum has been described as water-lily peat (W. Spackman, Jr. . and S. Stout, pers. comm. 1986) and radiocarbon dated atover 10,000 years. Underlying the entire deposit was a grayPleistocene sand.The chronometric placement of Windover skeletal mate- rial is based on a series of radiocarbon dates (Table 1 ). Thesedates were obtained directly from human bone, from the topand bottom of vertical burial stakes, peat above, within, andbeneath human bone, and from multiple locations within thepond. Recent radiocarbon corrections (Beukens 1986) indi-cate the dates would cluster the human activities at Windover at approximately 7450 b.p. The radicKarbon dates place the utilization of Windover in a chronological period that is usu- ally considered Early Archaic in the southeastern UnitedStates (Milanich and Fairbanks 1980). CULTURAL MATERIALS The Windover burials were accompanied by a diverse cultur- al inventory. Artifacts fabricated from animal teeth, antler,bone, seed, wood, shell and stone were found. Bone awlsand pins were the most commonly recovered artifact catego- ry and were manufactured from upland game including deer,canids, and felids. Drilled antler and manatee ribs and atlatlcups were also found. A bottle gourd (Lagenaria siceniria)accompanying a burial provides early evidence of curcurbitsnorth of Mexico; it predates other Lagenaria and virtually allother known Curcurbitacae north of Mexico (Conrad et al.1984; Kay et al. 1980; Prentice 1986). The status and mor-phology of the specimen is being carefully evaluated particu-larly in light of its early context (Newsom 1987).Additionally, textile materials were recovered from 37 ofthe burials. Seven twining/weaving variants have been iden-tified which include fine-balanced, plain-weave inner gar-ments, more durable complex-twined materials possibly rep-resenting blanketlike items, twined globular bags, open-twined items and matting (Andrews and Adovasio 1988).Macroscopic and microscopic thin sections of plant fibers inthe fabrics have been unsuccessful in identifying the plantspecies utilized. Morphological features that would normallyprove taxonomic criterion were apparently removed duringthe original processing of plant fibers or simply have not beenpreserved for 8(X)0 years (Andrews and Adovasio 1988;Newsom 1987). Phytolith studies also failed to provide infor-mation for the identification of plant fibers (Pipemo 1987). Zagreb Paleopathology Symp 1988 62 ? W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel Table 2. North American material with firm dating in excess of 6500 radiocarbon years B.P. (uncorrected) Provenience Analysis of 8000-year-old brain tissue from the Windover site ? 63 Table 3. Water chemistry of the Windover site (mg/1) Laboratory Number 878SP S79f 10604= 10491"^ Calcium 64 ? W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel Gross examination of the brain masses after removal fromthe skull disclosed the external gyral pattern of an atrophichuman brain shrunken to approximately 'A the original size.No meningeal coverings or blood vessels remained. Thebrain was tan-gray and had a soft, granular consistency. Thetwo cerebral hemispheres, divided by the longitudinal fis-sure, were identifiable, and the Sylvian fissure was visible on either one or both hemispheres. Cerebellar tissue containing visible folia was present below the occipital lobes. The re-gion of the brain stem in all cases was amorphous and finer Figure 4. Magnetic resonance image, 1 cm thick, of medialportion of adult male brain 57-300, sagittal section, speci-men facing right. Skull removed and brain embedded in agar(uniform medium gray). Brain material is light gray. Severalgross anatomical features are identifiable: A. occipital pole;B. frontal pole; C, lateral ventricle; D. cingulate gyrus. Im-ages produced by a Technical Teslacon 0. 15T resistive mag- net unit. Machine and pulsing techniques u.sed in routine clinical practice. structure could not be identified. Transverse slices of theremaining material exposed parietal, temporal, and occipitallobes with peat filling all fissures. Additionally, internalstructures such as the thalamus, basal ganglia, and ventricu-lar system were clearly visible (Figure 5). The overall im-pression was that although shrunken and altered in consisten- cy, gross anatomical features were present.A more detailed analysis of tissue structure was conductedby light microscopy. Representative samples taken from thecerebral hemisphere, cerebellum, and brain stem of bothbrains were processed for light microscopy. Sections werestained with silver axon stain (Seiver-Munger), hematoxylinand eosin (H&E) for nuclei, and luxol fast blue (LFB) formyelin (Luna 1968). The silver-stained, H&E, and LFB sec-tions resembled cerebral cortex and contained yellow granu-lar pigment, often in pyramidal shapes, corresponding to theremains of neurons (Figure 6A). The cyto-architectural pat-tern was similar to that of fresh cerebral cortex tissue. Occa-sional processes consisting of parallel, arrayed fibers extend-ing to the cortical surface, as well as horizontal, arrayedfibers within the subcortical white matter, were present. Nomaterial staining as nucleic acid could be identified, althoughclear areas the size and shape of nuclei were apparent withinthe granular pigment (Figure 6B). Sections of cerebellumcontained preserved Purkinje cells arranged in the spatialpattern seen in contemporary cerebellar tissue (Figure 6B). Asection of the pons contained the typical pattern of crossingpontocerebellar tracts as well as cortical spinal tracts dividedby remains of pontine nuclei (Figure 6C). Cellular processesin all sections were negative for silver stain but showed mod-erate staining throughout with myelin stains.No connective tissue elements were identified with Mas-son trichrome staining for collagen. Immunoperoxidasestaining for glial fibrillary acid protein (GFAP) and S-lOOprotein was also negative. Figure 5. Coronal section through agarose gel-embedded ancient brain of male 57-55 (right), and a similar sectionof a contemporary brain (left). Although the old brain section is surrounded by peat and has undergone somefragmentation, many gross anatomical structures are present. Two cerebral hemispheres and their gyral patternsclearly visible. /4, interhemispheric fissure; fl, corpus callosum;C. lateral ventricle; D. insular cortex; ?, putamen;F. internal capsule; C, thalamus; H. third ventricle. A subtle distinction between grey and white matter is stillapparent. Zagreb Pateopathotogy Symp. 1988 Analysis of 8000-year-old brain tissue from the Windover site * 65 ''I 66 ? W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. DickelB\ Figure 1. A. Scanning electron micro-graph of cerebral cortex. Remains ofneuropil made up of intermingling tu-bular processes can be seen. Occasion- al structures representing neuronal re-mains can be identified at lower left.Bar = 5 ^.m. B. Electron micrograph ofpyramidal neuron of cerebral cortex.Cell shape can be inferred from in-cluded lipofuscin granules (Luna1968). These electron dense granulesshow characteristic peripheral vacuole(inset). Remainder of cell shows finelygranular, moderately electron densematerial with a clear region in center(also seen by light microscopy), whichmay represent nucleus (Luna 1968).Two circular profiles at upper right rep-resent remains of neuritic processes.(xSOOO, inset x 22,000). Scanning electron microscopy revealed a background ofprocesses and presumptive neurons observable as accumula-tions of granular structures with an outer membranelikecovering (Figure 7A). Transmission electron microscopy in-dicated the processes have a pattern reminiscent of myeli-nated structures; however, myelin lamellae were not identi-fied. No organelles associated with neurons or theirprocesses were present. The most striking finding was anaccumulation of electron dense bodies which correspondedto the yellow, granular pigment seen by light microscopy(Figure 7B). These granules resemble lipofuscin pigment(Tauboldetal. 1975; Adams and Lee 1982:234-237). Consi- stent with this interpretation was the finding of more pigmentin the older brain (female) than in the younger brain (male). ISOLATION AND DEMONSTRATION OF HUMAN DNA Nucleic acids were extracted and purified from 15g of rela-tively peat-free cortex by solubilizing, chloroform-phenolextracting, and centrifuging in a CsCl-ethidium bromidedensity gradient. Material banding at a density of 1 .55 g/ccwas collected and identified as DNA by DNase sensitivityand RNase resistance. High molecular weight DNA of 8-20kilobases was clearly present in an ethidium bromide stainedgel of this DNA (Figure 8. left).To determine whether this DNA was of human origin, a gelwas blotted and hybridized to a probe specific for humanmitochondrial DNA (miDNA) (Chang and Clayton 1985),The probe hybridized to appropriate sized species in un-digested brain DNA demonstrating that human mtDNA waspresent (Figure 8, right). To confirm the presence of humanDNA a dot blot of 80()()-ycar-old DNA was probed with anAlu repeat sequence (Figure 8, right). The Alu sequence hybridized to old human DNA but not to a peat sample fromthe same level. The experiment was repeated several timesusing DNA samples from different old brains with similar results.The total yield of DNA was about 1 ^.g/g tissue, or 1% ofthat normally isolated from fresh tissue. Also, the amount ofmtDNA present in the old DNA sample appears low relativeto total isolated DNA. A comparison of hybridization sug-gests that about 0.05% of the total old DNA was mtDNA;DNA isolated from fresh brain tissue yields 0.5%- 1%mtDNA. Quantitation of Alu sequences on dot blots allowedan independent estimate of the fraction of human DNA se-quences in the old DNA samples (data not shown). We esti-mated that Alu sequences were present at 1% of the level ofthat from an equivalent amount of human placental DNA.The low yield of human mtDNA sequences could have sever- al potential causes: preferential loss of mitochondrial se-quences may occur during extraction; preferential degrada-tion of mitochondrial sequences may occur during 8000years or during the immediate postmortem period; and signif-icant amounts of nucleic acids from the surrounding plantmaterial may be present in the old-brain cortex sample. If thelatter situation is the case, the apparent fraction of any specif-ic human sequences would be diluted by plant DNA se-quences. Although the surrounding peat does contain aboutthe same amount (on a per weight basis) of DNA as braintissue, this DNA does not hybridize to the human mtDNAprobe (Figure 9).When the mtDNA was digested with Eco R I , the expected(Anderson et al. 1981) 8kb fragment which should appear after hybridization with the probe was not present (Figure 8, right). However, partial conversion of open-circular to linearmolecules did take place, as would be expected if only afraction of the Eco Rl recognition sequences were present. Ztign'h PaleopalhoUffty Symp. 198fi Analysis of 8000-year-old brain tissue from the Windover site ? 67A B C D Figure 8. Identification of human mtDNA sequences in DNA troni 8UUU-year-old adult male brain. Total DNAisolated and purified as described in text. An aliquot was digested with EcoRI and electrophoresed on a 1 % agarose gelalong with an undigested aliquot and samples of authentic human KB cell mtDNA treated similarly. After staining andphotography, gel was blotted and hybridized to a human mtDNA-specific probe (Chang and Clayton 1985), washed andautoradiographed. Central lanes containing enzymes, buffers, and carrier tRNA used in extraction, and enzymedigestion showed no hybridization to probe. Lane A, undigested KB cell mtDNA; lane B, EcoRI-digested KB cellmtDNA; lane C. undigested ancient DNA; lane D. EcoRl-digested ancient DNA. OC, L. and EcoRl refer to positionsof open- (nicked) circular, linear, and 8050-base pair (bp) EcoRI (D-loop-containing) fragment of KB cell mtDNA,respectively (Anderson etal., 1981; Houcket al., 1979). Left: Ethidium-stainedgel. /?/g/ir.Autoradiograph of blottedgel. Lanes A and B were exposed for 3 days, lanes C and D for 7 days. Resistance to enzyme digestion is an intrinsic property of theold DNA because a bacterial plasmid DNA mixed with thisDNA sample did digest to completion under the same condi-tions. The inability to completely digest the DNA may be dueto base modification leading to a loss of restriction endo-nuclease site recognition.The old DNA lacked supercoiled, covalently closed cir- cles (Figure 8, right). The reason for the absence of super-coiled molecules has not been investigated further at present,but many spontaneous processes can lead to single-strandnicks in DNA, converting covalently closed molecules toopen-circular forms (Vinograd et al. 1965). Multiple single-stranded nicks or damage resulting in a double-stranded scis-sion would lead to linear, full-length molecules, as was seen.High molecular weight and a surprisingly high fraction ofintact open-circular mtDNA was observed in these DNAsamples (Figure 8). Both of these observations may be due toDNA damage caused by depurination leading to intcrstrand-crosslinking of DNA (Goftln et al. 1984). Crosslinkingwould raise the apparent double-stranded molecular weightof the DNA, greatly increase the lifetime of circular DNAforms, interfere with restriction digestions, and perhaps alsointerfere with DNA hybridization experiments by preventingstrand separation. This type of damage has been shown to beenhanced in aqueous solution (Goffin et al. 1984).The presence and condition of nuclear DNA was also in-vestigated. Restriction endonuclease-digested DNA was Zagreb Paleopathology Symp. J9H8 probed with radiolabeled nuclear DNA and RNA sequencespresent as multiple copies in the human genome (an Alusequence, a large and small ribosomal RNA) (Houck et al.1979; Long and Dawid 1980). None of these probeshybridized to restriction fragments of a defined size (data notshown). If nuclear DNA was damaged in a similar manner asmtDNA and largely resistant to restriction endonuclease di-gestion, discrete restriction fragment bands of multicopy orsingle copy genes would not occur in hybridization experi-ments. In contrast, mtDNA occurs as a small 16 kb circularmolecule and migrates as a discrete species without depend-ing upon recognition of specific undamaged sequences by restriction endonuclease; therefore, it can be detected in hy-bridization experiments. Alkaline cleavage of the 8000-year-old DNA also reveals a significant amount of DNA damage(data not shown). It is estimated that these alkali-sensitive sites, many of which may represent apurinic nucleotides, arepresent at the 1% level.An attempt was made to clone and compare DNA se-quences from several brains with nucleotide sequences ofgenes or other DNA sequences already known. Thus far, oldbrain nucleotide sequences have not corresponded to anyknown DNA sequence. A small library of DNA fragmentswas constructed using a partial Alu I digest and an M13cloning vector. Approximately 1000 clones containing smallinserts (50-1000 bp) were isolated and 90 were screened forhomology to human mtDNA, human Alu rep)eat sequences. 68 ? W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. DickelA B C D E Table 4. sites where brain li^ucs have been foundLocations Dales Condition^ Reference Figure 9. DNA dot blot comparing amount of human Alusequences (plus pBR322 plasmid DNA) in 8000-year-oldDNA, nearby peat DNA, and contemporary human DNA.Cloned Alu sequence (in pBR322) was nick translated andhybridized to dot blot containing: lanes A and B, pBR322DNA 100ng(B-l)to0.2ng(A-5);/a/it'C, lOOngofhumanplacental DNA; lane D, 10 |i.g of 8000-year-old DNA fromSkull #57-77; lane E. 10 jjig of 8000-year-old DNA frompeat near bone deposits. Rows 2 to 5 contain serial 2-folddilutions of sample in row 1 . or human ribosomal genes. The inserts from three clonesexhibiting weakly positive hybridization signals were se-quenced. None showed significant (> 70%) homology toany of the three classes of target genes nor did these inserts(392 bp total) possess homology to any known DNA se-quence by computer analysis of the Genetic Sequence DataBank maintained by the NIH. This may not be surprisingsince only a small fraction (< 1 %) of the human genome hasbeen sequenced.An alternative approach to demonstrating the potentialhuman origin of some cloned fragments involved hybridizingSouthern blots of modem human brain DNA with probesmade from the cloned Alu inserts described above. Twelverandomly selected probes were made and hybridized. In twoinstances di.screte bands of modern human DNA hybridizedsuggesting that at least a portion of the old brain DNA is ofhuman origin. Again, the precise identity of the sequencesremains obscure. Discussion The Windover site yielded preserved brain tissue of humanorigin dating to the Early Archaic period. It is the oldesthuman soft tissue yet analyzed at a molecular level. An inter-disciplinary approach demonstrated the presence of human Fori Si. Marks, FL Analysis of 8000-year-old brain tissue from the Windover site ? 69 Bodies, however, can also be preserved in hot, dry en-vironments through accidental or intentional exploitation of natural desiccation. In these instances, the climate must bedry enough that dehydration of the bodies is rapid. Further-more, dry conditions must persist up to the time of discovery.Examples of this type of preservation are found in predynas-tic Egypt (before 2686 B.C.) (Smith 1902), Peru (Vrcelandand Cockbum 1980), the American Southwest (El-NajjarandMulinski 1980), Australia (Pretty and Calder 1980)and otherareas (Ascenzi et al. 1980).Other mummified or frozen remains have been found incold environments ranging from the high-altitude desert en-vironments of Peru and northern Asia to the arctic areas ofAlaska and Greenland (Artamonov 1965; Zimmerman andSmith 1975; Hansen et al. 1985; Dekin 1987). Under theseconditions dehydration may have taken place by sublimationof body moisture (Vreeland and Cockbum 1980). The boneand soft tissue in these samples are frequently in an excellent state of preservation (Vreeland and Cockbum 1980; Hansenetal. 1985).A variety of aqueous environments have yielded preservedtissue. The highly acidic (pH < 4) peat bogs of northernEurope have produced human remains with a remarkableamount of tissue preservation (Glob 1969; Fischer 1980).Skin and hair are intact (essentially tanned), intemal organpreservation is less predictable, and bone is usually highlydemineralized; less acidic conditions yield better preservedbone (Glob 1969).Ancient human remains from damp environments or non-acidic, water-saturated environments like Windover are rarer, but have occurred. Human skulls containing the appar-ent remnants of brain tissue were found earlier at severalFlorida sites (Royal and Clark 1960; Dailey et al. 1972;Clausen etal. 1979; Beriault etal. 1981). A Danish medievalcemetery yielded 56 of 74 skulls with brain material; like theWindover site no other soft tissue was preserved (Tkocz et al . 1979). Most of the bog bodies of northern Europe are fromacidic environments but some are found under less acidicconditions (pH 5-7.5), and in these cases the body is foundas skeleton or adipocere (Fischer 1980).Upon comparing descriptions of preserved tissue found atother archeological or forensic sites with the material found at Windover, we note that specimens and locations mostsimilar to Windover came from sites where adipocere forma-tion occurred. AdiptKcre (also known as "grave wax") is amixture of free fatty acids, primarily palmitic acid, and soapsresulting from the postmortem hydrolysis and hydrogenationof fats present in naturally occurring fat tissue in the body(Mant 1957;Zivanovic 1982:18-19). Damp conditions, fat-ty tissue, electrolytes (which may come from body fluids),and some putrification (to initiate hydrolysis) must be presentfor adipocere formation to occur (Mant 1957). Apparently atWindover, burial practices and physical and chemical condi-tions allowed putrification to begin but the process was halted before complete decomposition of brain tissue oc-curred.The conditions at Windover that appear most likely toenhance tissue preservation by inhibiting bacterial growthare the high sulfur levels in water and peat, the high amountsof minerals present in the water, and the anaerobic conditionswhich begin 30 cm below the peat surface. DNA within thetissue was preserved owing to at least two other factors: first,waterat Windover is nearly neutral (pH 5.3-6.8), particular-ly in the red-brown peat stratum; second, the anaerobic prop-erty of the water limits oxidative DNA damage. Thus, DNA alteration due to acid depurination. deamination. and oxida-tion was minimized. Interestingly, a low temperature maynot have been a factor in DNA preservation since modemsubsurface ground water temperatures are around 23?C. Al-though DNA has been isolated from tissues preservedthrough rapid drying (Paabo 1985; Higuchi et al. 1984;Rogers and Bendich 1985; Johnson et al. 1985), the present results show that tissues recovered from water-saturated en-vironments under conditions of anaerobia, neutral pH, andhigh ion levels also yield preserved DNA.In an archeological setting, DNA survival not only in-cludes chemical factors but also ethnological practices thatmay act to influence burial conditions and, thus, rate of tissuedecomposition and DNA survival. Individual differences intissue integrity may reflect variations in either burial environ-ment or the interval and conditions which prevailed betweendeath and interment, or both. Windover skeletal materialburied along the deeper edge of the pond was well preserved,but was disarticulated and appears to have been slowly trans-ported down slope. Burials in the more shallow edge of thepond, found in the third and final field season, were articu-lated but poorly preserved. There is no indication of second-ary burial at Windover, although the practice was widespreadin later New World populations (Ubelaker 1974; O'Shea1984; Churcher and Kenyon I960). The interment pattcmresembles Floridian aquatic burial practices occurring both earlier and later than the Windover site, possibly reflecting along-term or recurring religious theme in Florida (Royal andClark I960; Clausen etal. 1975; Beriault et al. 1981; Whar-ton etal. 1981; Sears 1982). It is clear that rapid interment is anecessary factor in tissue preservation in environments pro-moting rapid decomposition. Preservation may also reflectsex- and age-specific burial patterns. However, at Windover,brain material has been recovered from infants, adolescents,young and older adults representing both sexes, thus indicat-ing little status distinction in burial pattems. Agreement be-tween the ages of the peat surrounding the skeletal materialand the bone itself also suggests primary burials in shallowgraves. There are some indications that the bodies may havebeen deposited in water deep enough to require pointed "holddown" stakes and stakes of unmodified wood. We suggest,therefore, that in temperate latitudes of the New World, rapid, simple burial practices in an anaerobic, water- Zagrrb Puleopalhology Symp. 1988 70 ? W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel saturated matrix may be an important factor in soft tissue andDNA preservation.Nucleic acids (especially mtDNA) recovered from pre-historic populations could prove enormously useful in an-thropological studies of population genetics. Several re-searchers maintain reservations about the reliability ofmtDNA for cladistic studies (branching relationships) ( Jonesand Rouhani 1986; Slatkin 1987; Vawter and Brown 1986;Wainscoat 1987; Wainscoat et al. 1986). However, severalteams have suggested that restriction maps of mtDNA maybe useful for the study of cladistic relationships, timing ofdivergence, and investigations of multiple vs. single originsof populations. The characteristics that make mtDNA studies attractive are its high mutation rate (estimated 10 times thatof nuclear DNA) (Cann et al. 1984; Cann and Wilson 1983;Wainscoat 1987) and its uniparental and haploid pattern ofinheritance (Cann etal. 1987;Greenbergetal. I983;Johnson etal. 1 983 :Whittam etal. 1986; Wilson etal. 1985). Severalpilot studies have used mtDNA data to investigate the placeand timing of the origin of modem Homo sapiens sapiens(Cann etal. 1987; Denaro etal. 1981;Greenberget al. 1983;Johnson et al. 1983). 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Tissue sections demonstratedno paleopathology. Immunoglobulin may be present and will besought. Blood types and most any genetic parameter may be pre-dictable. Zagreb Paleopathology Symp 1988 Diagnosis of thalassemia in ancient bones:Problems and prospects in pathology Antonio Ascenzi, A. Bellelli, M. Brunori, G. Citro, R. Ippoliti,E. Lendaro, and R. Zito Porotic hyperostosis" is a generic term applied to a type ofbone lesion characterized by a symmetrically distributed in-crease in the volume of the skeleton, associated with a reduc-tion of the bone texture. Such a type of lesion was recognizedfor the first time by Cooley and Lee (1925) as a featurepeculiar to thalassemia. Subsequent investigations (Moseley1963; Ascenzi 1976.1979) deeply modified the originalview, so that nowadays it is quite obvious that porotic hyper-ostosis can be induced by any disease that leads to an increasein bone marrow volume, causing the skeleton to adapt itscapacity to contain the excess of hemopoietic marrow. Themost profound changes of porotic hyperostosis are seen inchildren, and they diminish as the individual approachesadult life (Caffey 1951). This agrees with Neumann's law inwhich half of the bone marrow is adipose in the adult, whilethe entire long bone marrow is hemopoietic in the child.Because of this, the adult can double the volume of hemo-poietic marrow without any change to the skeleton; on theother hand, even a limited hyperplasia of the hemopoieticmarrow induces in the subadult a volumetric increase in thebone marrow. A list of conditions inducing porotic hyper-ostosis has been compiled by Moseley (1965). and the sub-ject has been reviewed by Ascenzi (1976,1979). In theory,any condition that abnormally increases the rate of blood cellturnover can produce porotic hyperostosis. Disea.ses knownto do this include: congenital hemolytic anemias (thalasse-mia, sickle cell disease, hereditary spherocytosis, hereditary elliptocytosis. hereditary nonspherocytic hemolytic anemia),iron deficiency anemia, cyanotic congenital heart disease,polycythemia vera in childhood.From what is reported above it may be inferred that, inpaleopathologic terms, porotic hyperostosis is the only suita-ble evidence for the existence of medullary hyperplasia, ei-ther primary or secondary, when the skeleton is the onlytissue which time has preserved. However, skeletal remainsshowing porotic hyperostosis have been unable so far to pro-vide unequivocal information on the specific disca.se syn-drome which led to bone lesions. Zagreb PaUopathotogy Symp. 1988 Starting with these premises, we attempted to remove am-biguities for the diagnosis of thalassemia in skeletal remainsby examining the possibility that hemoglobin arising frompostmortem lysis of the erythrocytes may remain adsorbed tothe bone and be specifically detected. In a previous paper(Ascenzi et al. 1985) we provided evidence that hemoglobinis indeed measurable in skeletal remains dating back to En- eolytic age using an immunochemical technique. This dis-covery encouraged further investigations, and in this paperwe present additional progress toward an unequivocal diag-nosis of thalassemia in skeletal remains with porotic hyper- ostosis. Materials and methods Samples (lumbar vertebrae, skulls and other bones) wereobtained from the Verano cemetery of Rome (samples buriedfor 15 to 30 years), from the S. Senatore Catacumbae inAlbano Laziale, Rome (samples dating back from the first tothirdcentury of thisera), from the Necropolis of Porto (IsolaSacra, Rome, second century B.C.) and of Castiglione(Rome, 1000 B.C.).Bones were frozen in liquid nitrogen and crushed intopowder with a hydraulic press. The powder was extractedwith 6M urea for 4 hours at room temperature and neutral pH . The extract was filtered and urea was removed by means ofgel permeation chromatography on Sephadex G25 (Phar-macia, Sweden).Antiserum against human apohemoglobin (globin) wasraised in adult male rabbits with three subcutaneous inocula-tions of 0.8 mg of the antigen in complete Freund adjuvant.Hemoglobin constituent alpha and beta chains were preparedas by Bucci and Fronticelli (1965) and antisera against thetwo purified chains were obtained following the same pro-cedure. The content of hemoglobin remnants in bone extractswas determined with the immunoblot technique employing aBio Dot apparatus (BioRad, U.S.A.); solutions of apo-hemoglobin, alpha and beta chains were employed as stan-73 74 ? A. Ascenzi, A. Bellelli, M. Brunori, G. Citro, R. Ippoliti, E. Lendaro, and R. Zito % I lUO 200Antigen (ng) 300Figure 1 . Reaction of antiglobin rabbit antiserum againstliuman alpha and beta chains. dards. Quantification was achieved by integration of dot in-tensity using a LKB Laser Scanner densitometer and digitalintegration. Results Apohemoglobin (globin), alpha chains and beta chains wereused to standardize rabbit antisera raised against humanglobin. The results of one experiment illustrating this pro-cedure are shown in Figure 1 . Lumbar vertebrae extracts were tested with the same anti-serum and the content of hemoglobin in the skeletal remainsestimated by comparison with the standard curves. As al-ready shown qualitatively (Ascenzi et al. 1985), hemoglobinor hemoglobin fragments can be determined quantitatively inbone extracts with this technique. The average hemoglobincontent of lumbar vertebrae from adults buried for 1 5 years is0.7 to 1 fig/ 100 gram of dry powder (Table 1 ).A larger amount of titratable material is extracted from thelumbar vertebrae of younger individuals. As a general rule,the younger the individual, the higher the hemoglobin con-tent of the bone extracts, as may have been anticipated.Skull and other bones were used to determine the correla-tion between hemoglobin content and anatomy and physiol-ogy of the skeleton. It was found that, for the same individu- al, the absolute amount of hemoglobin detected from bonepowder varies markedly with the type of bone examined.Highly vascularized bones, whose marrow exhibits higherythropoietic activity, are (as expected) much richer in titra-table hemoglobin than bones with low or absent erythropoie-tic activity. Data in Table 1 report one example by comparingthe hemoglobin content of the lumbar vertebrae and the skullof an infant. Table L Content of hemoglobin (or hemoglobinfragments) in lumbar vertebrae extracts (except D2 = skull); quantitation with antiglobin rabbit antiserum Sample Age of Time elapsed Hb ng/lOO g bonesubject pom death () = No. of testsA senescent 15 years 0.16-0.2 (3)B adult 15 years 0.9-1.0(3)C adult 15 years 0.7-1.0(3)Dl infant 15 years 1.1-1.6(3)D2 infant 15 years 0.2-0.4 (3) Table 2. Content of hemoglobin (orhemoglobin fragments) in lumbar vertebraeof adults at different times after death (inyears) Sample Time elapsed Hb iig/100 g bonefrom death () = No. of testsA Diagnosis of thalassemia in ancient bones ? 75 Discussion Literature cited The results described above demonstrate that the immu-nochemical technique employed in this work is sufficiently sensitive and reliable to allow quantitative titration of hemo-globin and its constituent polypeptide chains in bone ex-tracts, even some thousands of years after burial of the indi- vidual. It is important that, as expected, the results indicatethat bones with higher erythropoietic activity contain greateramounts of titratable hemoglobin or hemoglobin fragmentsthan those characterized by reduced erythropoiesis. More-over it is clear from data in Table 2 that, within the accuracyof the methodology, no significant decrease of hemoglobincontent is observed with the archeological age of the speci-men, within a range of 15-2000 years. Previous results ( As-cenzi et al. 1985) indicated a loss of immunochemicallytitratable hemoglobin with time of burial, but it may be thatcharacteristics of the soil, humidity, or other interferencesmay be more important than age after death in determiningthe final content of detectable protein. It should moreover beemphasized that some uncertainties about the quantitativeestimate of hemoglobin in bone extracts remain, owing tothe interferences by false positive immunochemical reac-tions.As an example, it may be mentioned that two samples oflumbar vertebrae of adult humans from different burial sites(both approximately 2000 years old) were tested against anaffmity chromatography purified antialpha chain Ig fractionof the rabbit antiserum as well as against the antialpha de-pleted fraction of the same serum. The hemoglobin content inthe two tests was comparable (1-3 |xg/IOO g), while thenonhemoglobin reactivity was zero in one specimen andalmost eight times higher than that of hemoglobin in the other.Up to now. the immunochemical technique has been ap-plied only to morphologically normal bones, but it may bepossible to determine the content of hemoglobin remnantseven in bones whose morphology indicates hyperactiveerythropoiesis. As reported above, differential diagnosis ofchronic anemias with increased but insufficient compensa-tory erythropoiesis is usually impossible on the mere anatom-ical evidence of porotic hyperostosis. In this respect, theimmunochemical technique employed here represents a pos- sible tool for an unequivocal diagnosis of alpha and betathalassemias (and possibly other hemoglobinopathies) invery old skeletal remains. Further work along these lines is inprogress. Asccnzi. A. 1976. Physiological Relationship and Pathological In-terferences Between Bone Tissue and Marrow. In G.H. Bourne,cd.. The Biodwmislry and Physiology of Bone. 403-444. NewYork; Academic Press.1979. A Problem in Paleopathology: The Origin of Thalas-semia in Italy. Virchows Archiv A Pathological Anatomy andHistology. 384:121-130.Ascenzi, A.. M. Brunori. G. Cilro. and R. Zito. 1985. Immu-nological Detection of Hemoglobin in Bones of Ancient RomanTimes and of Iron and Eneolithic Ages. Proceedings oj the Na-tional Academy of Sciences. 82:7170-7172.Bucci, E., andC. Frontieelli. 1965. A New Method for the Prepara-tion of Alpha and Beta Chains of Human Hemoglobin, yourna/ ofBiological Chemistry. 240:PC 551 . Caffey, J. 1951. Cooley's Erythroblastic Anemia. Some SkeletalFindings in Adolescent and Young Adults. American Journal ofRoentgenology and Radium Therapy. 65:547-560.Chalevelakis. C, J.B. Clegg. and D.J. Weatherall. 1975. Im-balanced Globin Chain Synthesis in Heterozygous p-Thalas-semic Bone Marrow. Proceedings of the National Academy ofSciences. 72:3853-3857.Cooley, T B . . and P. Lee . 1 925 . Series of Cases of Splenomegaly inChildren with Anemia and Peculiar Bone Changes. Transactionsof the American Pediatric Society. 37:29-30.Moseley. J.E. 1963. Bone Changes in Hematologic Disorders(Roentgen Aspects). Orlando, Fla.: Grune and Stratton.1965. The Palcopathologic Riddle of 'Symmetrical Os-teoporosis. " American Journal ofRoentgenology, Radium Thera-py and Nuclear Medicine, 95:135-142. Summary of aiidif.nce discussion: Before one can attempt to correlate porotic hyperostosis with the chemical findings of globinpattems common to thalassemia, one must develop laboratorymethods not only for alpha and beta chains but also delta and gam-ma. The work presented in this study used trabecular bone becau.seof its hematopoietic marrow and therefore because hemoglobin waspresent there in vivo. Unfortunately during interment its porosity also invites diagenetic changes which might alter protein structure.Use of ribs as source material might minimize the diagenetic haz- ard. Dental pulp is even more sheltered from the environment.Conceivably the problem of antibodies against alpha and betachains also cross-reacting with gamma chains might be preventedby raising antibodies in appropriate animals against an antigen com-posed only of a peptide, preferably one with a known amino acidsequence; even better would be production of a monoclonal anti-body in the usual manner. Considering the small quantity of proteinpresent in fossil material, the use of radioimmunoassay methodol-ogy would appear to be desirable. Zagreb Patfopathotogy Symp. 1988 Trends and perspectives inpaleoparasitological research U.E.C. Confalonieri, L.F. Ferreira, A.J.G. Araujo, M. Chame,and B.M. Ribeiro Filho This report presents some methodological questions in-volved with our research on parasites from archeologicalmaterial in Brazil. Our investigations deal mainly with para- sitological findings in human and animal coprolites fromSouth American archeological sites and rarely with mum-mies, since, for paleoecological and paleoanthropologicalreasons, mummies are not common in Brazil. A review ofhelminths in mummified human remains has been presented recently (Home 1986:4-5).The first finding of parasites in archeological material wasin 1910, when Ruffer found Schistosoma haematobium eggsin renal tissue of Egyptian mummies, and paieoparasitologyhas been growing ever since as a scientific discipline. Theterm "paieoparasitology" was first used by Jean Baer(1971:317), although he mentioned it only parenthetically,commenting on the study of the coevolution of hosts andparasites. It acquired its definitive meaning after the firstpaper of Ferreira et al. (1979) and is widely used today tocharacterize the study of parasitic forms in archeological material. After some decades of research, interesting find-ings have been obtained, and new questions arise concerningthe interpretation of these findings. In this report we relateour experience regarding the use of some methods in pal-eoparasitological investigation as well as difficulties in theinterpretation of the data.In a recent review, Reinhard et al. (1988) discussed theprincipal techniques for isolation of parasitic forms fromcoprolites in soil and fecal deposits from archeological sites,and thus these will not be commented upon here.In paieoparasitology as well as in paleopathology sensu stricto, the main methodological question is the reliability ofthe diagnosis of the material. Our experience primarily in-volves the study of eggs and larvae of intestinal parasitichelminths found in archeological material from South Amer-ica. These differ to some extent from those in the Old Worldmaterial (see below).The methodological issues with which we deal involvethree main aspects: ( 1 ) identification of the zoological origin of the material found (human or animal?); (2) recognition ofthe possible morphological alterations in the parasitic forms resulting from the desiccation process in archeological de-posits or from other physical and biological events duringmany centuries; (3) better techniques for studying parasitemorphology, aimed toward their specific identification. It is necessary to stress that the approach to these questionsis based on knowledge from zoological and morphologicalsciences, biometrics, electron microscopy, and biochemis- try. We will comment only on analysis of helminths, since theothercommon intestinal parasites, the protozoans, are poorlypreserved and can rarely be found.The first problem faced by paleoparasitologists is the iden-tification of the origins of coprolite material found free inarcheological sites, that is, outside mummified bodies. Itmust be stressed there is an important difference regardingthe contents of parasite-containing archeological sedimentsfrom the New World and the Old World. Because the latter sites are mostly historical and urban, the possibility of mis-diagnosis lies between human coprolites and fecal materialproduced by domestic animals. In the American sites, at leastthose from South America, human coprolites have beenfound in places which could have been also occupied only bywild animals, since the South American Paleo-Indian did notdomesticate animals. Therefore we are doing surveys at thearcheological sites in the semi-arid regions of Brazil to in-crease our knowledge of the morphological aspects and con-tents of the feces of recent local fauna, basically the sameanimals as from the prehistoric Holocene. This approach wasinitiated by Fry (1977:7) and is being used to describe the size, form and contents of fresh animal feces as well as feces naturally and artificially desiccated. With this we intend toprepare a catalogue to serve as a guide for the identificationof coprolites. So far the results are encouraging because ofthe peculiarities of South American fauna in general, particu-larly at Brazilian excavation sites where there are few largeomnivorous or carnivorous animals whose feces could bemore easily misidentified as those of human origin. 76 Zagreb Paleopathology Symp 1988 Trends and perspectives in paleoparasitological research ? 77 However, for the assessment of the origin of coprolites wemust not forget other parameters, such as their food content as well as parasite composition known to be typical for thehuman host. Such parameters also include biochemical stud-ies which, although still in their infancy, certainly became animportant option after the identification of steroids from2000-year-old North American coprolites (Lin et al. 1978).A second problem relates to the possible structural modi-fications found in parasites contained in fecal material fromarchcological sites. Under the influence of environmentalfactors, parasite remains could undergo deformities and/or size modifications making their identification difficult oreven impossible. Such physicochemical processes could de-stroy parasitic forms in the fecal mass; these phenomenaseem to be responsible for the scarcity of findings of pro-tozoan cysts in coprolites. The first attempt to solve thisproblem came from the experimental approach inauguratedby Adamson (1976) when he assessed the persistence of eggsofSchistosoma sp. in artificially desiccated tissues in order toevaluate the actual frequency of these findings in Egyptianmummies. This approach was then extended to several nor-mal tissues as well as to soft tissue lesions (tumors, for exam-ple) by Zimmerman (1972,1977,1978) in an effort to assessthe possibilities of histopathological diagnosis in mummifiedbodies. More recently we started to study the morphologicalmodifications which occurred in helminth eggs and larvae after artificial desiccation and rehydration of fresh fecesusing different techniques. We have tested whether helmintheggs, such as those of the nematode genus Trichuris sp.(Confalonieri et al. 1985) and ancylostomids (Araujo 1987),whose diagnosis depends not only on qualitative mor-phological characteristics but also on size variations, wouldundergo significant alterations in their dimensions.So far these experiments have demonstrated that the desic-cation process does not cause deformities in these biologicalstructures that would hinder an adequate identification.Finally, detailed morphologic study of parasites found inancient material should be considered in qualitative as well asin quantitative aspects. In the former case, the differentialdiagnosis rests on detectable microscopic differences ofclosely related taxa. For this purpose the best technique isscanning electron microscopy, which can reveal variations inthe surface relief of eggs and larvae of helminths. A com-parative morphological study using this technique is pres-ently underway in our laboratory. It focuses on larvae ofAncylostomu duodenale and Necator americanus, the mostcommon human hookworms whose desiccated forms cannotbe easily separated with the light microscope.Diagnosis of some parasites depends on biometric evalua-tion. This includes the ova of Trichuris, the helminth mostcommonly found in South American coprolites, but also verycommon in European archcological deposits. These arebeing studied with some taxonomic techniques, such as theStudent t-test, for small samples (Sokal and Rohlf 1969:223). The test was applied to the identification of eggs of this genusfrom small fragments of coprolites from South American sites (Confalonieri 1988) under circumstances in which mor-phological criteria to the identification of the fecal materialcannot be used. In such cases in which several species ofTrichuris have overlapping size ranges, including the human T. irichiura, the statistical procedure is useful since it indi-cates in probabilistic terms the possibility for human origin ofthe material.We are using, again with Trichuris eggs, a new biometricparameter for a better discrimination of the different species.This is the linear regression coefficient between length andwidth of the eggs, already used by Joyner and Norton (1980)in the specific diagnosis of protozoan oocysts. Thus we canadd another variable for a more complete morphologicalevaluation of the egg of each species. This parameter wasshown to be especially useful for the differential diagnosis ofeggs of T. Irichiura and T. suis. two sister species commonlyassociated in archcological material from Europe (Jones1982).In summary, advances in techniques and methods appliedto paleoparasitological investigation are the result of newapproaches from biomedical and zoological sciences. In thefuture these will provide a greater reliability for identificationof parasitic diseases in pre- and protohistorical populations. Literature cited Adamson, P.B. 1976. Schistosomiasis in Antiquity. Medical Histo- ry. 20:176-188.Araujo, A.J.G. 1987. Paleoepidemiologia da Ancilostomose.D.Sc. dissertation, Ensp, Fiocruz, Rio de Janeiro.Baer, J.G. 1971. Animal Parasites. New York: McGraw-Hill.Confalonieri, U.E.C. 1988. The Use of Statistical Test for the Iden-tification of Helminth Eggs in Coprolites. Paleopathology News-letter. 62:7-8.Confalonieri, U.E.C, B.M. Ribeiro-Filho, L.F. Ferreira, andA.J.G. Araujo. 1985. The Experimental Approach to Paleo-parasitology: Desiccation of Trichuris irichiura Eggs. Paleo-pathology Newsletter. 5 1 :9- 1 1 . Fferreira, L.R, A.J.G. Araujo, U.E.C. Confalonieri. 1979. Sub- si'dios para a Paleoparasitologia do Brasil I. Parasites En-contradosemCoprolitos noMunicipiodc Unaf. MG.ResumoslVCongresso Sociedade Brasileira Parasitologia. Campinas.Fry, G.F. 1977. Analysis of Prehistoric Coprolites from \Jli\\. An-thropological Papers, vol. 97. University of Utah.Home, P.D. 1986. Helminthiasis and Mummified Human Re-mains. Abstract. 13th annual meeting of the Paleopathology As-sociation, Albuquerque. New Mexico.Jones. A. KG. 1982. Human Parasite Remains: Prospects for aQuantitative Approach. In A.R. Hall and H.K. Kenward, eds..Environmental Archeology in the Urban Context. Council forBritish Archeology Research Report. 43:66-70.Joyner. LP., and C.C. Norton. 1980. The F.imeiha acer\'ulinaComplex: Problems of Differentiation of Eimeria acenulina. E. mitis and E. mivali. Protozoological Abstracts, 4:45-52. Zagrrb Paleopathology Symp. 1988 78 ? U.E.C. Confalonieri, L.F. Ferreira, A.J.G. Araujo, M. Chame, and B.M. Ribeiro Filho Lin. D.S.,W.E. Connor, L.K. Napton, and R.F. Heizer. 1978. TheSteroids of 2000-Year-Old Human Coprolites. Journal of LipidReseunh. 19:215-221.Reinhard, K.J., U.E.C. Confalonieri, B. Herrmann, L.F. Ferreira,and A.J.G. Araujo. 1988. Aspects of Paleoparasitological Tech-nique: Recovery of Parasite Eggs from Coprolites and Latrines.Homo. 37:217-239.Ruffer, MA. 1910. Note on the Presence of "Bilharziahaematobia"in Egyptian Mummies of the Twentieth Dynasty (1250-1000B.C.). British MedicalJournal. 1:16.Sokal, R.R., and F.J. Rohlf. 1969. Biometry: The Principles andPractice of Statistics in Biological Research. San Francisco:W.H. Freeman.Zimmerman. M.R. 1972. Histological Examination of Experimen-tally Mummified Tissue. American Journal of Physical An-thropology. 37:271-280.1977. An Experimental Study of Mummification Pertinentto the Antiquity of Cancer. Cancer, 40:1358-1362.1978. An Experimental Base for Paleopathologic Diag- nosis. Transactions and Studies, College of Physicians ofPhila-delphia. 45:299-305. Zagreb Paleopathology Symp. 1 9HH Taphonomy of spontaneous ("natural")mummification with applications tothe mummies of Venzone, Italy Arthur C. Aufderheide and Mary L. Aufderheide Soft tissue preservation ("mummification") of human re-mains is of more than curious interest. Information of inter-pretive value applicable to epidemiology, parasitology, an-thropology, archeology, and many other fields has beenextracted by appropriate laboratory technology applied tosuch tissues (Cockburn and Cockbum 1980:1-8). In mostinstances postmortem preservation of soft tissues is the resultof specific, anthropogenic efforts directed at such an out-come. Methods have varied from evisceration and desicca-tion by heat in the Chinchorro culture of northern Chile 8000years ago (Allison et al. 1984) to the modem techniquesusing intra-arterial injection of protein-denaturing chemi- cals.While the effectiveness of the different methods varies, inmost cases the principle of the technique employed is self-evident. However, in certain human mummies no evidenceof anthropogenic, conservational effort is apparent, nor arethe mechanisms involved in such apparently spontaneousmummification processes obvious (Fornaciari 1982). Someof these are desert burials where the combination of heat andthe capillary action of sand are probably the principal ele-ments causing moisture removal from the body before softtissue dissolution is completed (Cockbum and Cockburn1980:140). Many of the other cases, however, deal with hu-man bodies interred under conditions not normally expectedto conserve soft tissues, such as subterranean tombs fre-quently carved out of rock, commonly beneath a church orother religious structure (Kleiss 1967:208), hence their col-lective appellation "catacomb mummies."This communication identifies the principal mechanismsinvolved in postmortem soft tissue lysis and the factors po-tentially available to cause "natural" mummification by re-tarding or arresting these processes. As an example, we ex-amine these possibilities in the case of sp<)ntanet)usmummification of a group of human mummies in Vcnzone,Italy. The report concludes with identification of specific defi- cits in our knowledge of such processes, and the researchrequired to provide the information base necessary to under-stand the biological process of spontaneous mummification. Mechanisms inhibiting postmortemsoft tissue lysis Normally, dissolution of soft tissues after death is achievedby enzymatic action. These enzymes are derived from threesources: (I) body tissues themselves, principally intracellu-lar enzymes, mostly of lysosomal origin; (2) bacteria, com-monly from the colon; and (3) insects from the environment.Properties shared by most enzymes include considerable specificity in the molecular stmcture of their substrate as well as a high degree of sensitivity to environmental changes oftemperature or acidity (pH) and to the presence of heavymetal ions. Furthermore all enzymes need a liquid medium inwhich to operate. Prevention of postmortem soft tissue lysis("mummification") in any given situation can therefore beexpected to involve one or more of these areas of vul- nerability resulting in partial or total inhibition of enzyme action. For example, one of the mentioned factors may pro-duce partial suppression of enzyme action, retarding the dis-solution rate sufficiently to permit an arid environment todesiccate the soft tissue and prevent further enzyme activity(Evans 1963:3-22). THERMAL ACTIONCooling and freezing to preserve perishable foods are partof our everyday experience. Not only the well-publicizedmammoths of Siberia (Orslanov et al. 1980:1-5) but alsohuman bodies have been preserved by this method. The latterinclude Greenland Eskimos (Hansen and Gurtler 1983), the "Prince of el Plomo" mummy from Chile? a nine-year-old Zagreb Paleopathology Symp. 1988 79 80 ? Arthur C. Aufderheide and Mary L. Aufderheide sacrificial victim entombed above the frost Hne on an Andeanmountain at an ahitude of 5400 m (Mostny 1957; Schobinger1966), Scythian tribal chiefs (Artamonov 1965) and Arcticexpedition members (Beattie 1983; Paddock etal. 1970) bur-ied in tombs dug into permafrost areas. Although most ofthese were probably continuously frozen, cooling near butnot necessarily below the freezing point (as in Arctic summerthaw periods) may inhibit enzyme action at least to the pointof profound retardation, as it did in several 650-year-old Inuitbodies from Alaska (Zimmerman and Aufderheide 1984). Ofinterest here are Micozzi's experimental taphonomy studiesdemonstrating delayed soft tissue putrefaction at summeroutdoor temperatures following a brief period of body freez-ing immediately after death (although the mechanical effectsof freezing actually hastened disarticulation). Micozzi( 1 986) felt this was the result of substantial intestinal bacteri- al mortality during the period of freezing.Warming the body may also retard putrefactive chemicalreactions. Since intestinal bacterial growth in vitro fre-quently ceases at incubation temperatures only a few degreesabove body temperature, the delaying effect of wanning maybe operative both at the bacterial level as well as creating anenvironmental temperature substantially deviant from theoptimum for some enzymes. Heat generated by intestinalbacterial activity in a living individual is normally di.ssipatedby intestinal wall blood flow. When this cooling flow ofblood ceases after death, intra-abdominal temperatures havebeen shown to rise. Native Aleuts exploited this preservingeffect by first heating their deceased tribal leaders' corpsesover a fire and then placing them in a cave continuouslywarmed by a natural volcanic heat source (Alexander 1949;Zimmerman et al. 1981:640) In the southwestern UnitedStates, bodies of pre-Columbian North American nativeswere sometimes buried in stone-lined cists exposed to the hotsummer sun. Conceivably, elevated ambient temperaturemay have been the principal factor in delaying putrefactiveenzyme activity until the corpse became very dry (El-Najjar et al. 1985). Such effects probably require substantial tem-perature elevations since only mild rises, although perhapsinhibiting bacterial growth, may accelerate the proteolyticactivity of certain enzymes. CHEMICAL ACTION There are few well-documented instances of spontaneousmummification largely due to an environmental al i erationOF pH, although this possibility is seldom pursued vigorouslyby investigators. The well-known tissue-preserving effect ofencasing a corpse in highly alkaline, powdered lime testifiesto its potential effectiveness. It is conceivable that waterpercolating through a limestone soil may become sufficientlybasic to paralyze enzymatic activity when it saturates a bodyburied therein.Heavy metals are powerful enzyme poisons. This is, forexample, the principal mechanism of lead toxicity in living individuals. Arsenic is so effective that it was used com-monly as an intra-arterial injection method of embalming byAmerican morticians until the early part of this century(Snow and Reyman 1977). Arsenic was accumulated duringlife in the bodies of pre-Columbian natives of northernChile's Camarones Valley as a result of drinking water fromthe valley's arsenic-contaminated river. This may have con-tributed to the excellent state of preservation present in thesebodies (M.J. Allison, pers. comm.).The ABSENCE OF OXYGEN is commonly invoked as an ex-planation for postmortem soft tissue preservation, though itis difficult to identify a well-controlled, laboratory studyestablishing this conviction. The astonishing quality of softtissue preservation in the body of a Chinese noblewomanfrom 100 B.C. has been attributed to the assumed anoxic tombenvironment, though the assignment of oxygen absence asthe principal factor in that case was done by exclusion ofother apparent possibilities (Wu et al. 1980).In addition to the action of heavy metals and the chemicalmethods listed below, occasionally specific antimicrobialSUBSTANCES may be present which delay degenerative pro-cesses by inhibiting bacterial proliferation. Probably the bestknown of these is the production of tetracycline by the mold-like bacteria Streptomyces. Ingestion of this antibiotic by aliving individual for infection control has been found to causea specific, fluorescent staining of bone collagen. Detec-tion of a similar staining pattern in archeological (Nubian)bones (believed to be the result of eating Streptomyces-contaminated grain) demonstrated that accidental antibioticingestion occurred during antiquity (Bassett et al. 1980).Aspergillusfla\ us. which flourishes in grain, also produces achemical with antibacterial action: aflatoxin. Theoreticallysuch a mechanism might contribute to soft tissue preserva-tion after death.One reason living cells survive the frequently complexchemical milieu commonly present within intracellular en-vironments of living biological systems is that most enzymesare designed to respond to only a very narrow range of mo-lecular structures. This high degree of specificity for en-zymes' intended substrates makes possible the success oftissue preservation by the use of "fixing" substances likeformaldehyde or certain alcohols which so radically re-arrange proteins' molecular contour that proteases which arecommonly present post mortem no longer react with them.Tannic acid is a fixing agent commonly employed today bytaxidermists to preserve animal skins. The presence of tannicacid in many northern European swamps is believed to beresponsible for the frequently excellent preservation of the "bog people" mummies found within them (Glob 1965:1-45).Adipocere formation is initiated in the form of neutralfat hydrolysis by endogenous lipases subsequently modifiedby bacterial enzymes (usually of clostridial origin) resultingin the formation of a different group of fatty acids which are relatively insoluble and chemically poorly reactive. These Zagreb Paleopathology Symp. 1988 Taphonomy of spontaneous mummification ? 81 may form a shell around the body surface, physically shield-ing the enclosed viscera from external influence and paralyz-ing further bacterial growth and enzymatic action internallyby lowering the pH. These changes were thought to havebeen responsible for the preservation of two bodies sub-merged in water of known temperature for five years (Cottonetal. 1987). DESSICATION All enzymes can exert their action only in a fluid environ-ment. Hence, enzymatic tissue destruction can be preventedif sufficient water is removed from the tissue (desiccation), aprinciple employed commercially for preservation of fruitand other foods. In order to be the sole operating mechanismin natural mummification such water removal would need tooccur quite rapidly. There may be occasional situations inwhich this could occur (prolonged exposure to the summersun in Cairo, for example), but they must be exceptional, andmost naturally mummified bodies are not found in circums-tances where this could have been exclusively operative.Burial conditions which would encourage removal of bodyfluids by conduction (capillary action) could be expected toaccelerate the dehydration process in comparison to circums-tances dependent only on surface evaporation and convec-tion. For example, wrapping a corpse snugly in a woolblanket and interring it in sand may increase the rate of waterremoval from the body through the "wicking" etTect of thetextiles and sand. Furthermore, if the body position is verti- cal, enzyme-laden small-intestinal fluids will drain outthrough the perineum, sparing the viscera of the upper abdo-men and chest. In spite of such enhancing conditions, how-ever, it is probable that in most cases at least partial suppres-sion of enzymatic action by one or more of the other,previously discussed mechanisms may need to operate inorder to provide the time necessary for sufficient water re-moval from the tissues to prevent further enzymatic action bydehydration alone. The mummies at Venzone, Italy Resting at the junction of the Venzonassa Valley with that ofthe larger Tagliamento River, the small community of Ven-zone was strategically located to permit control of the flow ofmen and arms in ancient times to and from the Fruilian Plainthrough this narrow gap in the mountains of northeasternItaly near Trieste. Romans exploited its military virtue, but itwas not until a.d. 1258 that the first stone of the wall pres-ently enclosing the village was laid. While feudal lords viedfor her possession, Venzone's inhabitants were more con-cerned with the commercial and social activities of theirneighboring (and competing) community, Gemona. Whenthe latter erected a majestic cathedral, Venzonians expandedtheir small church of St. Andrew into a grand cathedral,consecrating it in 1338. Burial vaults constructed beneath its Zagreb Paltopalhology Symp. 1988 Stone floor served as the final resting place for clerics andimportant citizens during the subsequent five centuries. Oneof these bodies, relocated during construction work in 1679,was found to be mummified and was hastily hidden protec-tively in the underground tombs. Later remodeling expandedthe cathedral further. By the first quarter of the 19th centuryso many of the bodies in the subterranean church vaults hadbecome mummified that they attracted the attention of a phy-sician from the nearby community of Udine. F.M. Mar- colini. a medical staff member of the Udine municipal hospi-tal, reviewed these mummies in 1829. carried out an autopsyon one of them, and published his findings, providing de-tailed descriptions of 17 of them, including the names anddeath dates of many ( 1 83 1 :42- 1 2 1 ). By 1 850, 27 mummieshad been removed from the burial vaults, and eventuallythese were placed in glass-fronted display cabinets in thebaptistery adjacent to the cathedral where they attracted thecuriosity of many a visitor (Galassi 1950).Several mummies from this collection have been lost. Oneor two were transferred to Vienna shortly after Napoleonconquered the area and annexed it to Austria. Two are be-lieved to have been transported to a New York museum andtwo others to Rome or Padua. None of these have been lo-cated in recent times. In addition one was destroyed by Mar- colini's autopsy in 1829 (Galassi 1950).On 6 August 1950 Dr. A. Gallassi from the University ofBologna inspected the displayed mummies, compared themwith Marcolini's descriptions and found little change otherthan the loss of hair from a red beard in mummy No. 5 (Sacer-dote Mistrozzi). He also added his own descriptions of anadditional five mummies exhumed since Marcolini's visit(Galassi 1950).A total of 21 mummies continued to be displayed in thecathedral's baptistery until the tragedy of 1976. On May 6 ofthat year a vigorous earthquake centered near Venzonecaused considerable damage to the area, but a second one onSeptember 15 was of catastrophic violence and nearly lev-eled most of the buildings in this unfortunate community. Notonly much of the cathedral but also the entire baptisterycollapsed, partially or completely burying many of the en-closed mummies. A local naturalist led several volunteers ina mummy recovery effort. About half of the 22 bodies werefound reasonably intact. The remainder were disrupted,sometimes extensively. Some of the dismembered mummieswere reassembled with the aid of pre-earthquake photos, but it was fwssible to salvage only a total of 15 of the 22 damagedbodies. Exposure to the elements had resulted in some appar-ent dampness of the skin in many. Fearing bacterial or fungalgrowth, the restoring party washed the bodies with a mixtureof formalin and phenol, storing them in a room whose wallsthey washed with a similar solution. Further suppression ofmicroorganismal growth was achieved by lining the floor andpart of the room with formalin-soaked newspapers. Subse-quently the mummies were transferred to a metal hut wherethey have been displayed during the period of community 82 ? Arthur C. Aufderheide and Mary L. Aufderheide reconstruction until a building to house them permanentlyhas been completed (Mainardis 1983).When the cathedral was reconstructed and expanded in the14th century the new floor level was raised 1 .5 m. Most ofthe tombs 1 1 through 1 7 are constructed between the originalfloor level and that of the new. current one; the bottom ofthese tombs, therefore, is sealed by the original stone floor(Anonymous 1971:96). Tombs 1 through 10, however, wereconstructed under the floor level of the new, expanded por-tion and the bottom of these tombs consists only of soil.Interestingly, while skeletonized bodies were present in alltombs, mummies were found only in tomb numbers 1through 10.During periods of heavy rainfall and high stream levels,standing water has been observed in the tombs containingmummies, and such an occasion led the residents to removethe mummies from the tombs when they found some of thewood coffins flooded and a white fungus partially coveringthe surface of many of the mummified bodies within them.About 1829, B. Biasoletto, director of the Botanical Garden at Trieste, examined the mummies and identified the fungusas Hypha hombycina Pers., suggesting that the fungalgrowth, by extracting water from the bodies, may have beenresponsible for the process of natural mummification in thesecadavers. Except for Marcolini's (1831) suggestion of theaction of an acid gas from the soil and some adipocere forma-tion. Biasoletto's suggestions have remained the locally ac-cepted explanation of their mummification. MATERIALS AND METHODS Having obtained permission to view the mummies from theproper local authorities, the authors visited Venzone, Italy on13 December 1983. No permission to biopsy or dissect thebodies was requested and no such procedures were carried out. Local archeologists. naturalists, historians, and re-sidents with knowledge about the mummies and their tombswere interviewed. The mummies were inspected and two(numbers 1 and 8) were cultured for fungi by swabbing theirfacial skin and exposed leg muscle surface with sterile cottonand streaking these on slants of Sabouraud's agar tubes.These were incubated at room temperature for up to .severalmonths. Material from growth was transplanted into individ- ual Sabouraud's agar tubes and onto slide cultures. Micro-scopic examination of slide cultures and wet slide prepara-tions, together with gross culture characteristics, providedevidence for identification. A sample of light-gray sand andfine gravel soil from a recent building excavation adjacent tothe cathedral was procured after scraping away 5 cm of soilfrom the vertical face of the excavated pit wall at a depth of 22cm from the ground surface level.The roofs of many of the tombs in the front of the churchhad collapsed during the earthquake and were sealed withcement slabs for safety reasons, but the cavity of tomb 9 was filled with debris, exposing only a part of its intact roof.Samples of wood and brick were removed from the exposedroof of this tomb in the cathedral. Access to tomb 15 waspossible by removing its temporary wooden cover and de-scending cement steps leading to its interior. This was oc-cupied by a jumble of disintegrated and collapsed wooden coffins. Individual human bones were scattered throughoutthis conglomeration, mixed with a damp, powdery materialwhich also lined the floor under the coffins. Only soil at thefoot of the steps, away from the coffms, was dry and lightgrey, similar to the soil in the excavation pit adjacent to thecathedral. No stone floor was identifiable. Coffin wood andfloor soil were sampled from tomb 15. These samples werealso weighed, then dried to constant weight and their mois-ture content calculated. Soil specimens were analyzed forlead content by graphite furnace atomic absorption spec-trometry (Wittmers et al. 1981), and for mercury, arsenic,copper and cobalt by neutron activation analysis (the latterby Technical Services Laboratory, Mississauga, Ontario,Canada). Soil pH was determined by suspending the soil indistilled water and measuring the pH of the mixture with aComing pH meter (McLean 1980). Swabs of the coffinboards in tomb 1 5 and of the soil samples were also preparedfor fungus cultures as described above.Analytical results are itemized in Table 1 . DISCUSSION The geological structure of the Venzone area is almost en-tirely that of calcareous rocks (Mainardis 1976: 16). The highcarbonate content of the soil adjacent to the church and thatcomposing the floor of tomb 15 (Table 1) is consistent withlimestone. Surface and ground waters of such areas normallyare quite alkaline. The pH values of samples listed in Table 1 . however, range from neutrality to 6.0. This is probably alocal phenomenon secondary to industrial and other an-thropogenic acidic products affecting the soil sampled out-side of and adjacent to the church, while that of the tombfloor was undoubtedly contaminated with acidic tissue prod- ucts from multiple degenerating bodies. The neutral or slightly acidic values in these particular samples do not ex-clude an alkaline pH effect on tissue enzymes resulting fromperiodic tomb flooding by ground water seeping throughlimestone.Similarly, moisture content of the "dark" soil sample fromthe tomb floor is high. Since the normal soil color of this areais light grey, the dark color of this soil sample from beneaththe collapsed cotTins undoubtedly reflects substantial con-tamination with degenerating human tissue. The relativelylow moisture content of the boards and that of the bricks inthe tomb roof probably more accurately reflect the normal state of humidity in an empty tomb lined by normally hydro-philic dolomite rock and soil, as suggested by the nearly Zagreb Pult'opalholofiy Symp. I9fi8 Taphonomy of spontaneous mummification 84 ? Arthur C. Aufderheide and Mary L. Aufderheide surfaces and is thus unable to exert any significant preserving effect on deeper tissues. It appears improbable to us thatfungal growth contributed significantly to the desiccated state of the Venzone mummies.The mummy bodies were examined (limited to inspection)for gross evidence of molecular alteration of proteins and/orfat to a chemically inert state. Facial features were frequentlyreasonably intact. The skin over the thorax was riddled withinsect holes but was generally otherwise intact in many mum-mies. The anterior abdominal wall was frequently partially orcompletely absent; in these the exposed abdominal cavity rarely contained recognizable organs. Tissues comprisingthe perineum, gluteal areas, medial aspect of the thighs andposterior trunk were absent in most of the mummies? a pattern commonly present in naturally mummified bodiesplaced in a supine position post mortem and reflecting thegravitational distribution of enzyme-rich, intestinal digestivefluids. While admittedly adipocere formation is not alwaysobvious, only a few, focal areas (primarily facial) could beidentified which conceivably could represent such an altera-tion of fat . Certainly we could not confirm that the bulk of thetissue preservation was the consequence of a shell of protec-tive adipocere formation, nor was there any recognizableevidence of chemical protein fixation. The general conditionof the mummies surviving the earthquake was similar to thatdescribed by Gallassi in 1950. It appears unlikely that tomb temperatures ever reach thefreezing point. Midwinter temperature measurement (madeby the authors) of a sealed, nearly identical tomb beneath thestone floor of the church in a nearby community of Urbaniawas 18?C.In summary, consideration of factors possibly contributingto the natural mummification of these bodies suggests it isconceivable, though not established, that highly alkalineground water seeping through the surrounding area limestoneintermittently may gain access through the soil floors to thesebodies' tombs (though not as readily to the tombs with stonefloors in the rear of the church), transiently immersing thecorpses and raising their tissue pH at least temporarily to adegree sufficient to retard enzymatic .soft tissue destructionfor a period long enough to permit subsequent tissue desicca-tion by the hydrophilic effect of the dolomite soil. Alter- natively, postmortem enzymatic action on tissues could havebeen paralyzed by the presence of heavy metals or by acidicaction from degenerating textiles or other artifacts like cop-per, probably from coffin components or included contents(since area soils do not reveal excess quantities of at least themore common heavy metals). Cool but not frigid ambienttemperatures may have enhanced retardation of soft tissuedegeneration during winter burials, but it appears highly un-likely that natural preservation of these bodies was achievedthrough extreme thermal action (freezing or very high tem-peratures), by the mechanism of anoxia, by protein fixationor significant adipocere formation, nor by the dehydrating or antibiotic action of any fungus, including that of the organ-ism termed "Hypha bombycina."In brief, while application of our current information (re-garding spontaneous mummification) to the Venzone mum-mies makes certain possibilities more conceivable than oth- ers, it is not possible to establish the locally operativemechanisms with a desirable degree of certainty. Clearly,more precise predictions of such events will require a muchmore detailed understanding of postmortem changes, madepossible by a program of laboratory investigation designedfor that purpose. Research needs Presently, bodies preserved by spontaneous mummificationrepresent the most valuable form of human remains for bio-medical and anthropological study, since they retain theorgans bearing the anatomical, biochemical, immunologicalor microbiological evidence of the disease afflicting them,including the final, fatal episode. Postmortem degenerativeprocesses place constraints on the ability of our modem labo-ratory methods to extract the desired information from thesetissues. Detailed knowledge of these postmortem changeswould permit us to adapt our technology so as to maximizethe informational return.The broad generalizations necessary in the previous dis-cussion as well as our inability to identify unequivocally themechanisms producing the Venzone mummies reflect the relatively barren state of our knowledge about postmortemhuman tissue changes. In a few, restricted areas isolated re-ports permit the synthesis of at least a proposed chemicalsequence leading to a specific preservational product(adipocere) (Cotton et al. 1987), but every mechanism dis-cussed here needs to be studied in detail by developing anappropriate operational model in which the individual vari-ables of interest can be controlled. Measurement methods forthe various reactions studied need to be created. Effects of theindividual factors impeding or enhancing these reactionsneed to be identified and quantified. Following this the re- sults obtained in isolated tissue under controlled circums-tances then need to be evaluated under the infinitely morecomplex, field situations of the entire organism. While the "chemistry of death" (Evans 196.3: 1-87) is surely a compli-cated matter, it may be no more so than many which havebeen well defined in living organisms.Our understanding of postmortem tissue changes and thefactors affecting them will only be achieved by such orderlyinvestigations. Field observations unsupported by the con-trolled studies described above rarely provide informationapplicable to situations occurring under different circums-tances. Funding necessary to carry out such studies may bejustified by the obvious applications of the derived data toeveryday forensic problems of enormous medico-legal im-portance. Zagreb Paleopathology Symp. 1988 Taphonomy of spontaneous mummification ? 85 Appendix The authors arc very grateful to John Rippon, Ph.D.. Section ofDermatology. Department of Medicine. University of Chicago andPritzker School of Medicine, for the following information. In Mycologia Europaea. Vol. 1 , by Persoon. published in 1822.the following entry is found on page 65: Classis prima, Ordo primus;XXXV. Hypha. Flocciformis, mollissima ad tactum diffluens.fugax. Obs. Fungi sunt subterranei. aut in locis suf-focatis et cryptis vegetant. colore plerumquc albi. I . bombycina, subrotunda indeterminata. humida Ooccosgossypinos referens Hyphasma floccosum. Rehenti.sch.Flor. p.396. Dill. Hist. Muse. p.5,t.I.f.9. Dematiumbombycinum. Syn. fung. 6%. Hab in fodinis et ccllis,ligms et lapidibus adhaerens. Colore nivea . . . In Sylloge Fungorum. Vol.14, by P.A. Saccardo, published mPavia, 1899, by the author, the following entry is found on page1192: Mycelia sterilia, Hypha;HYPHA Pers. M.E.I, p.63, Hyphasma Rebent. Dematium Pars.Byssus L. pr. pr. ex emend.Humb.Dub. (Etym. hyphe texture). ?Rhabdi arachnoidei hyalini simplices v. ramosi. decum-bcntcs, fistulosi, continui, laxe intertexti, fugaces (aeriscontactu saltem) contabescentes v. confluentes. sporis de- stitute Mycetes subterranei in cryptis locisque sufFocatis, vegcti albi, aliorum procul dubie initia, ex loco lucisquedefectu pessumdati. hinc dubii. I. Hypha bombycina Pers. M.E.I, p.63, Byssus floccosaSchreb. Spic. 144, B. bombycina Nees Syst. f. 73,Hyphasma floccosum Rebent. Neom. p.396. Dematiumbombycinum Pers. Syn. p.696. Dill. Hist. t.I.f.9?Rhabdishyphoideis, simplicissimis, subparallelis, niveis, primumlaxe intertextis, hypham veluti gossypinam. elatam subro-tundam, mundissimam, dein collapsis, membranam com-pactam seu corium tenacellum mentientibus. Hab. ad ligna et alpides in caveis udis et fodinis minime rara inGermania.? 18-20 cm. alta et lata, ocissime gliscens. Literature cited Alexander. F. 1949. A Medical Survey of the Aleutian Islands. 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Direct Analysis for Lead in Milligram Quantities of BoneAsh by Graphite Furnace Atomic Absorption Spectrometry.American Jourmil of Clinical Pathology, 75:80-85.Wu. Z.B.. H.S. Tian. and Y.E. Zcng. 1980. Study of the AncientCorpse of the Western Han Dynasty Unearthed from Tomb No.168 on Phoenix Hill at Jiangling County (A Comprehensive Re-port). Medical Bulletin Wuhan Medical College. 1:1-8.Zimmerman. MR., and AC. Aufderheide. 1984. The Frozen Fam-ily of Utqiagvik; The Autopsy Findings. Arctic Anthropology.21:53-64.Zimmerman, M.R., E. Trinkhaus, M. LeMay, A.C. Aufderheide,T.A. Reyman, G.A. Marrocco, W. Ortel, J.T. Benitez, W.S. Laughlin, P.D. Home, R.E. Schultes, and E.A. Coughlin. 198LThe Paleopathology of an Aleutian Mummy. Archives ofPathol-ogy and Laboratory Medicine, 105:638-641 . Summary of audience discussion: In Israel a monk buried withintact clothing has been disinterred and found to be marvelouslypreserved. Other areas where spontaneous mummification has oc-curred in subterranean chambers include Urbania (northern Italy),Palermo (Sicily) and Guanamoto (northwestern Mexico). All ofthese occur in limestone areas but the mechanisms arc speculative.Recently in a medieval cemetery in northern England the very well-preserved body of a knight was found wrapped in a shroud and rolled up in a lead sheet. Clearly we need to study the phenomenonof spontaneous mummification by experimental archeological Zofin'h Pula'pathol(\i;\ Svmp. 19HS Soft tissue calcifications in paleopathology C.-A. Baud and Christiane Kramar C^alcified masses are rarely described in paleopathologicalliterature (because they are perhaps not always found). Astheir origin (Table I) and their interest may be varied, it isimportant, in the presence of cxtraskeletal calcifications, todistinguish ectopic ossifications, tissue calcifications, andcalculi.The diagnosis of some calcifications, owing to their at-tachment to the skeleton, is easy: for example, the stylohyoidligament (O'Carroll 1984), costal cartilages (McCormick1980) and myositisossificans(Lagier and Baud 1978). Whencalcifications are isolated, but identifiable owing to theirshape, diagnosis is also easy: the laryngeal cartilages ( Jurik1984), for example. When calcifications are not attached tothe skeleton and are without anatomical shape, the diagnosisis harder. As such examples we present pleural plaques,leiomyomas of the uterus, a tuberculous lymph node, and ahydatid cyst. Material and methods Pleural plaques were found with the osseous remains of menfrom three different medieval cemeteries; Collonge, Geneva,Switzerland, 10-1 Ic, grave 45, man of more than 60 yearsold (Baud 1972; Bonnet 1972); St. Matthieu's Church,Bemex, Geneva, Switzerland, 13- 14c, grave 44, man of 60years old (Kramar 1984), and St. Gervais, Geneva, Switzer-land, grave 27.The first leiomyoma of the uterus was found among humanskeletal remains from a Middle Neolithic population,Corseaux-sur-Vevey, Vaud, Switzerland, 4700-3490 B.C.(Kramar 1982; Kramar et al. 1983). The two others are fromEarly Middle Ages cemeteries: Sion Sous-le-Scex. Valais.Switzerland, 5- 10c, grave 37 and Ranees, Vaud, Switzer-land, 5-7c.The lymph node was found in a collective burial from theChalcolithic period. Dolmen des Peirieres, Villedubert,Aude, France (Roudil 1976).The hydatid cyst was found with the remains of a medievalchild 2-4 years old.All concretions were first macroscopically and radio-logically observed. Fragments of concretions were embed-ded in methyl methacrylate and sectioned for microscopic Zagreb Paleopathology Symp. 1988 examination in normal and polarized light. Ground sections10 jjL thick were decalcified in formaldehyde-formic acid andstained with van Gieson's picrofuchsine.Microradiographs were made from sections 100 jx thick,according to the technique of Boivin and Baud (1984). Frag-ments from the 100-^, sections were reembedded in epoxyresin (Epon) forelectron microscopic examination. Ultrathinsections were decalcified and stained with phosphotungsticacid.An x-ray powder diffraction analysis was performed with aGuinier camera to determine the crystalline species, and anx-ray diffractometric recording, following the technique ofJacquet et al. (1980), for crystal size and/or perfection esti-mate. ResultsPLEURAL PLAQUES Macroscopically the pleural plaques were hard, of variablesize ( 14.5 X 1 3 cm the biggest; 7.5 x 4.5 cm the smallest; 4-5 mm thick), with an irregular surface structure. Radiographsreflected these differences with a disparity of absorption. Table l. Examples and etiology ofsome soft tissue calcification Etiology Examples DevtlopmentaJ Aging ImmobilizationTraumaInflammatory Tumoral Stylohyoid ligamentCrowned odontoidLaryngeal cartilagesCostal cartilages Articular tissues Myositis ossificans Pleural plaquesLymph nodeHydatid cystsLeiomyoma 87 88 ? C.-A. Baud and Christiane Kramar The microradiographs showed large areas with a high anduniform degree of mineralization, and others characterizedby a lower degree of mineralization and the presence of somelens-shaf)ed cavities of the size of the bone osteocytic la-cunae. Examination of the decalcified sections showed areasstained red with van Gieson's method, fibrillar texture, and(jositive birefringence. Electron microscopic study indicatedthe presence of collagen fibrils with characteristic striation;these fibrils were scattered in highly mineralized zones andpacked close in a parallel direction in the less mineralizedones.X-ray diffraction patterns were characteristic of apatite,with large crystals in the more mineralized zones (fine lines)and small crystals in the others (broad lines).After dissolution of apatite, we looked at the presence ofminerals known to provoke fibroses (Le Bouffant 1974): wefound nothing to support the hypothesis that minerals in theenvironment of these individuals are agents in this etiology(Constantopoulos et al. 1985). LEIOMYOMAS OF THE UTERUS Macroscopically the Neolithic leiomyoma was a sphericalmass (56 x 52 x 45 mm) with a smooth but irregular surface.X-rays confirmed its mineralized nature. Examination of thedecalcified sections showed the presence of collagen fibers;van Gieson's method stained them in red, and birefringencewas positive; no bone structure was observed. Microradio-graphs showed a high and uniform mineralization. Electronmicroscopy confirmed the presence of collagen fibrils withthe characteristic striation. The mineral material was apatite;crystal size and/or perfection were good.The dimensions of the two others were 46 x 32 x 25 mm(Sion Sous-le-Scex) and 30 x 26 x 18 mm (Ranees). Thesection of these calcifications showed the characteristicwhorllike pattern of the leiomyoma (Bartholomew et al.1961).A similar case of calcified uterine leiomyoma was reportedby Strouhal and Jungwirth (1977). LYMPH NODE The lymph node was a reniform mass (12x8 mm) with alamellar capsule with numerous perforations enclosing tworounded nodules. Microradiographs of the sections showedthat both capsule and nodules were highly mineralized. His-tological study of decalcified sections showed fibrillar struc-ture with a positive birefringence and a red van Gieson'sstaining, particularly in the surface layers of the node. X-raydiffraction revealed two mineral components: apatite in theperiphery, and apatite together with whitlockite in the center,as we observe in calcified tuberculous lesions (Lindgren1961:81-89;Lagieretal. 1966; Sakae and Yamamoto 1987). The shape, size, and fibrous capsule with numerous perfora-tions suggest a lymph node; calcified foci formed of apatiteand whitlockite suggest calcification of tuberculous origin. HYDATID CYST The cyst was an ovoid, hollow concretion 1 cm in diameter,with a smooth internal surface and an irregular external sur-face. The observation of a section with polarized lightshowed tangled collagen fibrils. All these facts characterizea cyst wall (Weiss and M0ller-Christensen 1971; Price1975:366-367; Wells and Dallas 1976; Ortner and Putschar1981).The mineral component was apatite only; this is compat-ible with an hydatid cyst (Lagier et al. 1966: 158). Differential diagnosis of soft tissuecalcifications It is important to distinguish between ossifications, calcifica-tions, and calculi.We have first to differentiate tissue calcifications from calculi. Concretions in the body cavities (gastroliths, entero-liths, bezoars, etc.) and calculi in excretory ducts (salivary,biliary, urinary) also contain an organic matrix (Kahn andHackett 1984), but in small quantity and not of collagenousnature (not stained with van Gieson's picrofuchsine).Among tissue calcifications we have to distinguish be-tween a calcification and an ossification: calcification corre-sponds to adeposit of mineral material in aconnective tissue,more or less altered, which shows the presence of scatteredcollagen fibrils and a very high degree of mineralization;ossification has a characteristic texture with an oriented dis-position of collagen fibrils and osteocytic lacunae. We haveto note that a tissue calcification tends to be replaced by anossification (Kuhlmann 1934), which explains the coexis-tence, in pleural plaques, of ossified zones and calcifiedzones.The study of the mineral component of a calcification canpermit the substantiation of an etiological diagnosis: most ofthe soft tissue calcifications are formed of apatite only, andthey correspond to a broad spectrum of pathological condi-tions (Lagier et al. 1966:158). Mixed crystal deposits, with apatite and whitlockite, are found predominantly in lesionsof tuberculous or parasitic origin (Lagier et al. 1966:159). Literature cited Bartholomew, L.G., J.C. Cain, G.D. Davis, and A.H. Bulbulian.1961 . Misleading Calcific Shadows in the Abdomen. Postgradu-ate Medicine. 30:51-52.Baud, C.-A. 1972. Unc Plaque Pleurale Calcifiee: Etude Ultra- structurale et Cristallographique. Genava. 20:196-199.Boivin, G., andC.-A. Baud. 1984. Microradiographic Methods forCalcified Tissues. In G.R. Dickson, ed., Methods of Calcified Zagreb Pateopaiholofiy Symp. 1988 Soft tissue calcifications in paleopathology ? 89 Tissue Preparation. 391-412. New York: Elsevier Science Pub-lishers. B.V.Bonnet, C. 1972. L'Ancicnne Eglisc de Collonge (Collonge-Bellcrive. Geneve). Geneva. 20:131-203.Constantopoulos, S.H.. J. A. Goudevenos, N. Saratzis, A.M. Lun-ger, l.J. Seiikoff, and H.M. Moutsopoulos. 1985. Metsovo Lung:Pleura! Calcification and Restrictive Lung Function in North-western Greece. Environmental Exposure to Mineral Fiber asEtiology. Environmental Research. 38:319-331.Jacquet, J. J.M. Very, and H.D. Flack. 1980. The 2 Determinationof Diffraction Peaks from "Poor" Powder Samples: Applicationto Biological Apatite. Journal of Applied Crystallography,13:380-384.Jurik, A.G. 1984. Ossification and Calcification of the LaryngealSkeleton. Acta Radiologica. 25:17-22.Kahn, S.R., and R.L. Hackett. 1984. Microstructure of DecalcifiedHuman Calcium Oxalate Urinary Stones. Scanning Electron Mi-croscopy. 2:935-941.Kramar, C. 1982. La Necropole de Corseaux-sur-Vevey: Etude An-thropologique et Description Archeologique. These 2041,Geneve.1984. Plaques Pleurales Chez un Homme du Moyen Age:Etude Radiologique, Microscopique et Cristallographique. FifthEuropean Meeting of the Paleopathology Association, 199-210.Siena, Italy.Kramar, C, C.-A. Baud, and R. Lagier. 1983. Presumed CalcifiedLeiomyoma of the Uterus. Archives ofPathology andLaboratoryMedicine. 107:91-93.Kuhlmann, K. 1934. Zur Atiologie, Entstehung und Bedeutung derPleuraverkalkungen bzw. Pleuraverknocherungen. Fortschritteaufdem Gebiete der Rontgenstrahlen. 49:147-154.Lagier, R.. and C.-A. Baud. 1978. Some Comments on Paleopa-thology Suggested by a Case of Myositis Ossificans Circumscrip-ta Observed on a Medieval Skeleton. Journal of Human Evolu-tion. 9:9-13.Lagier, R., C.-A. Baud, and M. Buchs. 1966. CrystallographicIdentification of Calcium Deposits as Regards Their PathologicalNature, with Special Reference to Chondrocalcinosis. In H.Fleisch, H.J.J. Blackwood, and M. Owen, eds.. Third EuropeanSymposium on Calcified Tissues. 158-162. New York: Springer-Verlag.Le Bouffant. L. 1974. Investigation and Analysis of Asbestos Fi-bers and Accompanying Minerals in Biological Materials. En-vironmental Health Perspectives. 9:149-153. Lindgren, I. 1961. Anatomical and Roentgenologic Studies of Tu-berculous Infections in BCG- Vaccinated and Non-VaccinatedSubjects. With Biophysical Investigations of Calcified Foci. ActaRadiologica (supplemcntum) 209: 1 - 101 . Stockholm.McCormick, W.F. 1980. Mineralization of the Costal Cartilages asan Indicator of Age: Preliminary Observations. yourna/o/Foren- wc- Sciences, 25:736-741 . O'Carroll, M.K. 1984. Calcification in the Stylohyoid Ligament.Oral Surgery, 58:617-621.Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho-logical Conditions in Human Skeletal Remains. SmithsonianContributions to Anthropology. 28:229-233. Washington, D.C.:Smithsonian Institution Press.Price, J.L. 1975. The Radiology of Excavated Saxon and MedievalHuman Remains from Winchester. Clinical Radiology. 26:363-370.Roudil. J.-L. 1976. Villedubert, Les Peirieres. Informations Arch-eologiques. Gallia Prehistoire. 19:553-555.Sakae, T., and H. Yamamoto. 1987. Crystals and CalcificationPatterns in Two Lymph Node Calcifications. Journal of OralPathology 16:456-462.Sirouhal, E., and J. Jungwirth. 1977. Ein verkalktes Myoma uteriaus der spatcn Romerzeit in Acgyptisch-Nubien. Milteilungender Anthropologischen Gesellschaft. 107:215-221. Vienna.Weiss, D.L., and V. Moller-Christensen. 1971. Leprosy, Echi-nococcosis and Amulets: A Study of a Medieval Danish Inhuma-tion. Medical History. 1 5 :260- 267 . Wells, C, and C. Dallas. 1976. Romano-British Pathology. Antiq- uity, 50:53-55. Summary of audience discussion: Interpretation of crystal characteristics of excavated calcified material is most useful if itslocation within the body is known precisely. In the thorax, forexample, it becomes more informative if it can be determinedwhether the calcified mass represents simple exudate or a pleuralplaque and whether costal periostitis was present. Archcologistsneed to be made aware of the importance inherent in such detailedobservations. Since Dr. Brothwell has observed bacteria in dentalplaque specimens viewed by scanning electron microscopy, a simi-lar search for mycobacteria in calcified material suspected to be oftuberculous origin appears desirable, as well as diagnostic immu-nological studies on protein included within calcified material. Zagreb Paleopathology Symp. 1 988 Technological innovations and discoveries in theinvestigation of ancient preserved man Peter K. Lewin Stereoscan imaging from composite"CT scans" Late in 1976 when the first computeinzed axial x-ray to-mographic machine (CT scan) was installed at the Hospitalfor Sick Children in Toronto. Dr. Harwood-Nash and I per-formed the first CT scan on an archeological specimen(Lewin and Harwood-Nash 1977). The specimen was thedesiccated brain from Nakht, an adolescent weaver from thefunerary chapel of Setnakht, who had lived in Thebes about3000 years ago. The images from Nakht 's brain demon- strated intact ventricular cavities and partial differentiation ofthe grey and white areas of the brain together with smallpostmortem cavities. The brain scan was followed by the first total body scan ofthe mummy of the priestess Djema "Etes' Ankh, dating fromabout ninth century B.C. Tomographic sections of the headshowed prosthetic artificial eyes set in the eye sockets. Sec-tions through the pelvis showed normal hip joints, and withinthe pelvis the remains of the uterus could be visualized(Lewin 1978). In the last two years in collaboration with John Stevens andJudy Trogadis at Toronto Western Hospital, who developedthe computer software for this project (Stevens and Trogadis1986), we have extended our noninvasive imaging tech-niques by constructing three-dimensional images from se-quential data obtained by the two-dimensional CT scan.A beautifully preserved head from the Greco-Romanperiod is shown in Figure 1 . Composite spacial see-throughreconstructions of ancient archeological specimens, usingcomputed axial tomograms, are presented in Figures 2 and 3. This technique can also be applied to other imaging meth-ods and enhanced with newer, digital processors. These new,nondestructive imaging methods would be invaluable in thethree-dimensional examination of mummified remains andtheir internal structures including archeological objects,keeping these valuable specimens intact for posterity.90 Figure I. Ancient Egyptian mummified head fromGreco-Roman Period. Electron microscopy of mummified tissues todemonstrate viral agents and their possibleviability Ancient Egyptian mummified material was first examined atthe ultrastructural level in 1966 (Lewin 1967) and demon- strated reasonable preservation of cellular organelles. Sincethen numerous tissues have been examined by electron mi-croscopy, the best preserved tissues often being skin, blood,muscles, and vessels.Viral agents have also been demonstrated, includingsmallpox-like particles from the mummy of Ramses the Fifth Zafireh Paleopathntofiy Symp. 19SH Innovations in the study of ancient preserved man ? 91 Figure 2. Computer-generated image of mummified head.(Photograph courtesy of P.K. Lewin, J.K. Stevens and J.Trogadis) Figure 3. Computer-generated image of skull from mum-mified head. (Photograph courtesy of P.K. Lewin, J.K. Ste-vens and J. Trogadis) (Figure 4) (Lewin 1984) and from a naturally mummifiedtwo-year-old infant from Naples (Fomaciari and Marchetti1986).The above methods and the recent use of DNA hybridiza-tion techniques are being used to determine the viability of atleast some of the genetic DNA content of ancient biologicalremains. It is possible that infectious agents are still viable,particularly viruses in ancient human and animal specimenspreserved in northern areas by permafrost. Literature cited Fomaciari. G., and A. Marchetti. 1986. Intact Smallpox VimsParticles in an Italian Mummy of the XVI Century: An Immuno-Electron Microscopic Study. Paleopathology Newsletter, 56;7-12.Lewin, P.K. 1967. Palaeo-Electron Microscopy of MummifiedTissue. A'amre. 2I3;416-417.1978. Whole Body Scan of an Egyptian Mummy UsingX-Ray Computed Axial Tomography. Abstract of a paper pre-sented to Paleopathology Association Meeting, April 1978. Pa-leopathology Newsletter. 22:T7-8.1984. "Mummy" Riddles Unraveled. Microscopy Societyof Canada Bulletin. 12:4-8.Lewin, P.K., and DC. Harwood-Nash. 1977. X-Ray ComputedAxial Tomography of an Egyptian Brain. International ResearchCommunication System. Medical Science, 5:78.Stevens, J.K., and J. Trogadis. 1986. Reconstructive Three Dimen- sional Electron Microscopy. Analytical and Quantitative Cytol-ogy and Histology, 8: 102- 107. Za^rfb Pateopatholony Symp. 1988 Figure 4. Smallpox-like viral particle found on the mummyof Ramses the Fifth (x 200,000) (Lewin 1984). SuiviMARV OF AUDIENCE DISCUSSION: The three-dimensional imagegenerated by computcri7ed radiology is sufFicicntly accurate to beusable tor forensic purposes especially in cases of only partial pres-ervation of cranial bones. The value of preserving such images ofbones scheduled for interment is potentially enomious. The presentresolution of I ..S mm is expected to be reduced soon to 0.25 mm oreven lower, which would permit evaluation of such areas as thepubic symphysis which are uniquely useful in paleopathology. Agood deal of ethnic variation remains to be included into the pro-grams, after which it may be possible to create a reconstructedimage of the .soft tissue on the basis of a "skull-scan." Harris' lines in adults: An open problem Lubos Vyhnanek and Milan Stloukal More than 30 years ago Harris drew attention to the characteristic meta-physeal transverse lines found in thex-ray pictures of the long bones, espe- cially in children. He rightly concludedthat these lines represented the conse-quences of the temporary arrest ofgrowth which could be caused by dif-ferent factors (Harris 1933). The term "lines" refers to the radiological pic-tures in reality; they constitute zones oflamellar bone (Figure 1) which appearas lines when tangentially projected inthe x-ray picture. They develop duringthe growth of the bones as the result of atemporary growth mechanism distur-bance of cartilaginous cells and of os-teoblasts (Goodman et al. 1984). Thesezones can be best demonstrated in thelong bones, although the temporary ar- rest of growth of course involves theentire skeleton (Steinbock 1976). Withrenewed growth and during its furthercourse, the zones remain in place andappear therefore successively more andmore distant from the epiphyseal levelin the diaphyseal direction. Theyusually?and in some cases veryearly?undergo resorption and disap-pear; in other cases they remain appar-ent up to an advanced age (Gam andSchwager 1967). In tribute to the authorwho described them the lines are calledHarris' lines.Even this very schematic presenta-tion of Harris' lines includes the fea-tures which it is necessary to rememberwith respect to their application in an-thropological research. In the first place, these lines never represent thefull registration of all periods of tempo- rary arrest of growth. Their absencenever means that the individual did not suffer from any disease or hungerperiod in his past history. The laws gov-erning the persistence of Harris' linesup to adult age are unknown. It cannotbe assumed that the most prominent ormost recent Harris" lines are preservedbecause clinical studies prove this isnot so.A broad variety of factors provokeHarris' lines (Cohen and Armelagos1984). Harris' lines are found after in-flammation of the upper respiratorypassages as well as after other infec-tious diseases, in diabetes, chronic ane-mias, chronic metal and other poison-ing, and after surgical interventions.Animal experiments demonstrated thatthey are induced by protein and vitaminA deficiency, and by fasting in general(Acheson and Maclntyre 1958). Duringlong-time follow-up of children it wasfound that the number of Harris" linesdoes not necessarily equal the numberof illness periods (Gindhart 1969). Insome cases the lines appeared evenwithout any proved cause.In clinical practice, Harris' lines inadults are not considered as clinicallyimportant and usually they are not men-tioned in interpretation of radiologicalpictures. In recent years a new interestin Harris' lines was raised by studies inwhich the authors tried to use them forpaleopathological purposes (Allison et al. 1974). Among studies which dealt ?y7* Figure 1 . Prominent Harris' lines at adistance of 45 mm from distal articularsurface of tibia. Photograph of sectionof bone. 92 Zagreb Paieopathology Symp. 1 988 Harris' lines in adults: An open problem ? 93 very thoroughly from different pointsof view with the incidence of Harris'hnes in ancient bone materials, wemention especially the studies of Wells(1961. 1967) and Kuhl (1977). CalvinWells introduced the Index of Mor-bidity, as the means to characterize apopulation group. The best preservedlong bone of the skeleton is always se-lected for study, and the number of Har- ris' lines in the entire population stud-ied is divided by the number ofobserved skeletons. Unfortunately,studies applying Wells' Morbidity In-dex do not mention if the number ofHarris' lines counted includes onlythose which completely traverse the fullwidth of the bone or those which arepartially preserved. In our opinion,these incomplete remnants of Harris'lines signal the period of temporarygrowth arrest in the individuals past asimportantly as the complete ones. Inaddition it is necessary to take x-raypictures of the evaluated bones in twoviews; the discrete shadow of Harris'lines may be seen only in one projec-tion.As an example of the incidence ofHarris' lines in a recent population wepresent the findings in a group of 160men with x-ray pictures of the lowerextremities examined for other than an-thropological reasons in one region ofCzechoslovakia. We followed the Har- ris' lines especially in the tibiae, wherethese lines appeared most prominentlyand where they could be recognizedmost securely. The average age of themen examined was 67.3 years, rangingfrom 49 to 88 years. With five excep-tions only, the childhood of all thesemen occurred during the period ofWorld War I. or the years close to it. Itcould be supposed that apart from theusual childhood infectious diseases,they were exposed to other similarprovoking factors during their growth,especially dietary deficiency. Never-theless, this study was not made to esti-mate the influence of different factors in the frequency of Harris' lines but tofollow the Harris' lines preserved in agroup of adult men at a certain individ- ual age and with a similar childhoodhistory.In this group of 160 adult men, Har- ris' lines were found in only 35 (21.9%)cases. This would imply that nearly80% of these men did not sutler fromany serious illness or hunger periodduring World War I, which is hardlyprobable. Harris' lines were bilateral in27 (77.1%) of the 35 men, on the rightside only in 3 (8.6%) and on the leftside in 5 (14.3%). The average age ofthe men with the Harris' lines was 68.5years (ranging from 62 to 84 years). Itdid not differ significantly from theaverage age of men without Harris'lines. In most cases more than two Har- ris' lines were present. Lines nearest tothe epiphysis were mostly complete;lines situated nearer to the center of thebone were often represented by theirdorsally and tibially preserved partsonly.The distance of the Harris' line to thedistal tibial articular surface was differ-ent in individual cases. In most cases itwas 2.5-3.5 cm, but in several cases itmeasured 6 cm and exceptionally 10cm. In bilateral findings the distance onthe right and left side was equal. Onlyin 2.8% of men?quite sporadic?wasit possible to identify Harris' lines notonly in the distal parts of the tibiae butin the proximal ends, too. In one ofthese findings the distance between thefirst proximal Harris' line and the prox-imal articular surface of the tibia corre-sponded with the distance between thefirst distal Harris" line and the distaltibial articular surface. In all cases ofproximal tibial Harris' lines, distal Har- ris' lines were present also. In only twocases did Harris' lines in the distal partsof the fibulae accompany those in thetibiae. Considering the total number oftibiae with preserved Harris' lines,these two fibula ca.ses are really excep-tional. We studied the coincidence of Har- ris' lines and the persistence of the epi-physeal line in the distal end of thetibia. The result in our group showedthat no less than 31 (88.6%) of the menwith Harris' lines aged 62 to 84 also hadpreservation of the epiphyseal line atthe same time. Only 4 men (11.4%)with Harris' lines failed to demonstratea recognizable epiphyseal line. In menwithout Harris' lines, the epiphysealline was visible in only 41 (32.8%).The association of simultaneous per-sistence of Harris' lines and of the epi-physeal line was statistically signifi- cant. In conclusion, we summarize ouropinions on the possibility of usingHarris' lines in the paleopathologicalanalysis of adults: 1 . It is necessary to consider Harris'lines in the skeleton of an adult individ- ual as an expression of a strikingly indi-vidual feature. The absence of Harris'lines can hardly represent secure evi-dence of the general state of health ofthe population because there are noidentified rules of their preservation upto adult age. 2. Asymmetry of the occurrence ofHarris' lines on the left and right side oflong bones is so exceptional that it ispossible to use either tibia for theirdemonstration and study. 3. In the evaluation of Harris' lines, it is necessary to base the result on x-raypictures in two views to demonstrateincomplete lines. 4. It is possible to use the frequencyof Harris' lines to characterize a certainpopulation group if it is rememberedthat Harris' lines are polyetiologicaland that the problems of their per-sistence up to adult age are not solved. 5. The statistical significance of thecoincidence of persistent Harris' lineswith the epiphyseal lines in our groupsuggests very interesting relationships. Zagreb Paleopathology Symp. 1988 94 ? Lubos Vyhnanek and Milan Stloukal Literature cited Acheson, R.M.. and M.N. Maclntyre.1958. The Eft'cLts of Acute Infection andAcute Starvation on Skeletal Develop-ment. A Study of Young Rats. BritishJournal of Experimenial Pathology,39:37-45.Allison, M.J. . D. Mcndoza, and A. Pezzia.1974. A Radiographic Approach toChildhood Illness in Precolumbian In-habitants of Southern Peru. AmericanJournal of Physical Anthropology.40:409-416.Cohen, M.N., and G.J. Armelagos. 1984.Paleopathology at the Origins of Agricul-ture; Hditors' Summation. In M.N.Cohen and G.J. Armelagos, eds.. Paleo-pathology at the Origins of Agriculture . 585-601. New York: Academic Press.Gam, S.M., and P.M. Schwager 1967.Age Dynamics of Persistent TransverseLines in the Tibia. American Journal ofPhysical Anthropology. 27:315-311.Gindhart, P.S. 1969. The Frequency of Ap-pearance of Transverse Lines in the Tibia in Relation to Childhood Illness. Ameri-can Journal of Physical Anthropology.31:17-22.Goodman, A.H., D.L. Martin, and G.J. Ar-melagos. 1984. Indications of Stressfrom Bone and Teeth. In M.N. Cohen andG.J. Armelagos, eds. , Paleopathology atthe Origins of Agriculture. 13-49. NewYork: Academic Press.Harris, H.A. 1933. Bone Growth in Healthand Disease. London: Oxford UniversityPress.Kuhl, I. 1977. Die Leichenbrande vomBrandgraberfeld auf der Dune Wissing.Gem. Halden. 213. Kiel, Germany:Kreis Wesel.Steinbock, R.T. 1976. PaleopathologicalDiagnosis and Interpretation. 46-55.Springfield, 111.: Charles C Thomas.Wells, C. 1961. A New Approach to An- cient Disease. Discovery. 22:526-531.1967. A New Approach to Paleo-pathology: Harris' Lines. In D. Brothwelland A.T. Sandison, eds. , Diseases ofAn-tiquity. 390-404. Springfield, 111.:Charles C Thomas. Summary of audience discussion: The "disappearance" of Harris' lines in adultsmay be an illusion, resulting from theirobscuration by the thickening of the grow-ing diaphyseal cortex; they may becomeapparent again ("reappear") followingdemineralization of the bone in the os-teoporotic patient. It is also important toremember that only those who sufler a tran- sient pulse of illness and recover promptly will develop them; the chronically ill andthe very healthy individuals do not developHarris' lines. Correlation between develop-ment of Harris' lines and dental hypoplasiais often not high because each responds todifferent stimuli or at least to different de-grees, but if one compares all microscopicdental defects the correlation is good. Zagret> Paleopalhotogy Symp. lV<'i8 Medical ceramic representation of nasalleishmaniasis and surgical amputationin ancient Peruvian civilization Oscar Urteaga-Ballon From 3000 years ago until the Spanishconquest, the central part ot the mightyAndean Mountains of South Americawas the center of some of the mostsplendid, ancient American civiliza-tions. The Inca empire was the last ofthose civilizations. It began in the Peru-vian lands and spread throughout partsof Ecuador, Colombia. Bolivia, Argen-tina and Chile (Larco-Hoyle 1938-1939; Mason 1957; Tello and Mejia1960; Bird 1962; Sawyer 1966). TheIncas considered themselves the directdescendants of the sun and moon,which they worshipped as their gods.The ancient Peruvians did not leave a written language, but in their metal art,pottery and textiles, they did leave agraphic sculptural language, which, ifone is prepared to do so, can be readlike the pages of a book. In the northcoast valleys of Peru began one of themost splendid civilizations of ancientPeruvians. The Mochica culture hadleft beautiful, realistic ceramic sculp-tures, which covered broad aspects ofMochica life, including special medicalcollections. In 1968 we published acomplete review of some chapters ofthe sexual behavior of ancient Peru-vians as shown in their ceramic art(Urteaga-Ballon 1968). These ancientpeople were [wwerful warriors withlarge conquering armies, but during pe- riods of peace they dcveU)pcd an out- standing civilization rich in artistic cul-ture.Much of what we know about theremarkable medical history of pre-Columbian Peru is the result of researchon the ceramic pieces of the ancientPeruvian civilizations. Many infectiousdiseases have been portrayed inceramic art. As a result of chronic war-fare, many people suffered serious le-sions which demanded different typesof surgical operations. Mutilation andamputation of the limbs were frequent.The most dramatic representations ofthe medical pottery are the cranial oper-ations (trephination), which were con-ducted by members of the Paracas civil-ization beginning more than 2000 yearsago.Two different types of ceramic medi-cal art serve to illustrate this rich andimportant source of information on an-cient medical traditions in the NewWorld. We first present some examplesof ceramic art showing evidence ofleishmaniasis, a condition well knownin modem Peru and often seen by meduring my career as a pathologist inPeru. We follow this with a brief reviewof a few cases of ceramic art exhibitingamputated limbs and the prosthetic de-vices that were often made to assist thepatient with at least some use of thelimb following healing of the amputa-tion stump. Nasal leishmaniasis Mucocutaneous leishmaniasis is achronic infectious disease caused bythe protozoan Leishmania hraziliensis.The disease was endemic in the ancientPeruvian lands, as it is found in theceramics of those cultures.Between 1 962 and 1 974 in the Muse-um of Paleopathology of Lima, Peru, Istudied 67 ceramic pieces in which thepre-Columbian Peruvian craftsmenrepresented different lesions of infec-tious and parasitic diseases. In this pa-per I show four ceramic representationsof mucocutaneous leishmaniasis repre-senting different stages of lesions af-fecting the nasal and oral cavities. As acomparative reference I include twoother paleopathological ceramic repre-sentations which prove the skill andknowledge of the ancient Peruvian phy- sicians.Figure 1 corresponds to the famousportrait-head vessel of the Mochicaceramic described by Larco-Hoyle(1938-1939) and Sawyer (1966). Itrepresents a congenital cleft of the up-per palate and lip. Figure 2 represents apunitive case with surgical mutilationof the nose and lips. Both pieces areexamples of the graphic realism of theancient Peruvian craftsmen.Figure 3 is also a Mochica portrait-head ves.sel which shows the first stage Zagreb Paleopathology Symp I9H8 95 96 ? Oscar Urteaga-Ballon 1 1 Nasal leishmaniasis and amputation in ancient Peruvian ceramics ? 97 Some paleopathologists have de-scribed these nasal and oral lesions aspathognomonic of a form of leprosy.Ortner and Putschar (1981). in their classic paleopathology book, havecommented on the findings of differentinvestigators in skulls found in a medi-eval Danish leprosy cemetery in 1953.All of them think that these nasal and oral lesions are characteristic of lep- rosy. However, they did not discard thept>ssibility that similar lesions could befound in tertiary syphilis and in lupus vulgaris.My experience in more than thirtyyears as a pathologist of tropical infec-tious diseases is different. Today, in thejungle of the Amazon River, leprosy isendemic. We have seen more than 300patients with leprosy there. Many ofthem were in the acute lepromatousstage and others had chronic, advancedlesions. Most of those patients had mi-croconfluent, nodular lesions of thenose. Some of them also had gran-ulomatous lesions in the nasal septumwith ulceration and perforation of theseptum, but we did not find one case inwhich the nasal septum and the palatebone were totally destroyed giving the classic appearance of a round, wide andlarge nasal cavity with nasal-oral com-munication.However, in the jungle of the Ama-zon River, mucocutaneous leishmania- sis is also endemic. We have studiedalmost 100 cases of these patients.More than 20 were in an advancedstage, showing the typical destructivelesions of the nasal septum and the pal- ate bones, exactly like the graphic rep-resentations in the ceramics of the an- cient Peruvians.Mitsuda and Ogawa (1937) reviewed150 autopsies in the Aisein NationalLeprosarium in Japan. On this subjectthey said. "Some leprotic periostitisand involvement of the osseous struc-ture are found in various bones, such asthe tibia and the phalanges." However,they did not describe any special naso- FiGURE 5. Ceramic representation of a case of mucocutaneous leishmaniasis. Third stage. Infection has destroyed nasal septum, rounding and widening nasal cavity.Peruvian Mochica culture. Lima, Peru.Figure 6. Ceramic representation of a case of mucocutaneous leishmaniasis. Last stage. Complete destruction of nasal cavity with partial resorption of hard palatebone. Peruvian Mochica culture. Lima, Peru.Figure 7. Ancient Peruvian skull with a case of mucocutaneous leishmaniasis,showing classical nasal and oral lesions of this disease. Nose is round and wide fortotal destruction of nasal bones. Part of palate bone also destroyed. Skull of Peru-vian mummy. Lima, Peru.Figure 8. Ceramic representation of face of a normal skull showing anatomicalproportion of size and shape of nasal and oral cavities, including septum. PeruvianMochica culture. Lima, Peru. Zagreb Paleopathology Symp. 1988 98 ? Oscar Urteaga-Ballon oral destructive lesions. Kean andChildrees (1942) made a summary of103 autopsies of leprosy cases at theGorgas Hospital, Canal Zone, Panama.They described the leprosy osseous le-sions as follows: "Amputation of onetoe 12, one or more fingers 14, leg 9,foot 1; absorptions of fingers 19, toes18, feet 3; gangrene of the toe 2, mis-cellaneous lesions 7." They also did notfind the naso-oral destructive lesions.Desikan and Job ( 1968) in the GeneralHospital in Vellore, India, reviewed 37autopsies of leprosy. They did not de-scribe one case of naso-oral destructivelesions.Enna (1968), in Ryukyu Island inOkinawa, studied 996 leprosy patientswith lesions showing advanced defor-mity; 15.2% had nasal deformities, butnot one had the osseous destruction ofthe oral and nasal cavities. Bernard andVazquez (1973) studied 60 necropsieswith similar results.However, other leprologists havefound some degree of destructive le-sions in the nasal cavity of leprosy pa-tients. Powell and Swan ( 1955), in theNational Leprosarium at Carville,Louisiana, in advanced cases of lep-romatous leprosy found that ulcerationand perforation of the nasal septumwere common, with destruction of nasal cartilage and bone resulting invarying degrees of "saddle" deformity.Kumar et al. (1979), in the LeprosyClinic in Chandigarh, India, described25 selected patients. Of these 88% hadnasal obstruction, while 48% and 32%had ulceration and perforation of nasalseptum. Barton et al. (1982), in theVictoria Hospital in Dichpalli, India,studied 62 patients of lepromatous lep-rosy; one of them showed a completelyperforated septum.Furthermore, in a North Americantextbook of pathology, Marcial Rojasand Kissane ( 1985) made more radicalaffirmations. They said that mucocuta-neous leishmaniasis produces "exten-sive destruction of the soft and underly- FiGURE 9. Mucocutaneous leishmania- sis. Total destruction of septum and de-formation of nose and lips. Photo fromAtlas of Tropical Pathology (Binfordand Connor 1976:207). ing hard tissues of the nose and pharynxproducing severe mutilation of theface."Finally, Binford and Connor (1976)make the most complete revision of lep-rosy and leishmaniasis. In Section 6 ofthis atlas, Binford and Meyers pub-lished 76 photographs of gross and mi-croscopic lesions of all types of leprosy.Despite the fact that some of their casesshow tremendous deformation of thenose and the lips, none of these patientsshow the destructive bone lesions intheir nasal-oral cavities. However, inSection 7 of the same atlas Connor andNeafie show one case of mucocutane-ous leishmaniasis with tremendous de-structive lesions. The authors say, "ABrazilian with mucocutaneous leish-maniasis has a destroyed nasal septumand deformed nose and lips" (F-3-B-6,page 261).We have included as comparison twofigures from this atlas. Figure 9 shows acase of mucocutaneous leishmaniasiswith a massive destruction of the nasalseptum and deformities of the nose andlip. Figure 10 corresponds to a case oflepromatous leprosy with tremendous 10 Figure 10. Lepromatous leprosy. Tre-mendous deformation of nose and lips,without destruction of nasal septum, incontrast to case of leishmaniasis inFigure 9. Photo from Atlas of Trop-ical Pathology (Binford and Connor1976:261). deformation of the nose and the lips,but with no destruction of nasal-oralbones.In medicine nothing is exact; we can-not say with certainty that the gran-ulomatous nasal-oral destruction ispathognomonic of one specific disease.According to its ancient and modem in-cidence, mucocutaneous leishmaniasisoccupied first place. Lepromatous lep-rosy is in second place. Tertiary syph-ilis and yaws are in third place. Rhi-noscleroma and other infectiousdiseases rarely produce this anatomicallesion.More important in this academic,historical discussion is the fact that an-cient Peruvian physicians had left in-disputable evidence of their knowledgeof some of the most complex chaptersof medicine. Their graphic ceramicrepresentations are unquestionable. Surgical amputation and limbprosthesesWe have studied 65 ceramic pieces inwhich the Mochica craftsmen repre-sented traumatic medical surgery. Zagreb Palenpalhftto^y S\mp t9HH Nasal leishmaniasis and amputation in ancient Peruvian ceramics ? 99 Among them were prostheses of the up-per and lower extremities. We selected12 of these cases, the first 4 represent-ing different types of limb amputationsand the rest being a complete sequenceof the prostheses operations.Figure 1 1 represents a case of an am-putation of the left arm. The personuses a short cape which had a false hand at the bottom. Figure 1 2 shows a case ofa bilateral arm amputation. Figure 13reveals an extensive operation with theremoval of the complete right arm. Amore radical surgical operation appearsin Figure 14: the patient has sufferedbilateral arm and foot amputations; it ispossible that these surgical mutilationswere done as a punitive sentence be-cause there are also mutilations of theupper lips and part of the wall of thenose.In the next eight ceramic pieces thecraftsmen represent a successful se-quence of a prosthesis of the leg andarm. Figure 15 shows the traumatolo-gist examining a patient's leg previousto the operation. Figure 16 demon- strates the second stage. The patient hasbeen operated upon recently. The twobones of the left leg appear through thesurgical wound. Figure 17 shows an-other patient who has been operated onsome time ago. The wound appearscompletely healed. Figures 18 and 19correspond to the fourth stage of theprosthesis operation. Two patients aretesting the prosthesis apparatus with thehand opposite to the amputated leg. InFigure 20 another patient appears withthe prosthesis attached to his left leg,and Figure 21 reveals the last stage ofthis traumatologic operation. The pa-tient is walking with the help of a caneand the prosthesis is attached to his leftleg.We did not find a complete sequenceof the prosthesis of the arms. However,we found two instances of patients withthe prosthesis attached to the arms. Fig- ure 22 shows one of these cases. Thepatient was a blind man who had a pros- FiGURE 1 1 . Amputation of left arm. Mochica culture, ceramic. Lima. Peru.Figure 12. Bilateral arm amputation. Mochica culture, ceramic. Lima. Peru.Figure 13. Extensive surgical operation of right arm. Mochica culture, ceramic.Lima, Peru.Figure 14. Bilateral arm and foot amputations. Mochica culture, ceramic. Lima,Peru. Zagreb Paleopathology Symp. 1988 100 ? Oscar Urteaga-Ballon Figure 15. Prosthesis of the leg. Traumatologist examining patient's leg previous tooperation. Chimu culture, ceramic. Lima, Peru.Figure 16. Prosthesis of the leg. Second stage. Patient has been operated upon recently. Two bones of left leg appear through surgical wound. Mochica culture,ceramic. Lima, Peru.Figure 17. Prosthesis of the leg. Third stage. Wound appears completely healed.Mochica culture, ceramic. Lima, Peru.Figure 18. Prosthesis of the leg. Fourth stage. Patient is testing prosthesis apparatuswith hand opposite to amputated leg. Mochica culture, ceramic. Lima, Peru. thesis attached to his right arm. Nineceramic pieces of the same Mochicaculture represent some prosthesis appa- ratus. They correspond to the legs,arms and hands. One of these piecesrepresents a surgical knife held be-tween the fingers. The surgical knifewas named "tumi" and the surgeonsused it in different types of operations.Some ceramic pieces represent the sur-geons with the tumi knife in their handduring a cranial trephine. The representations of lesions andprostheses, carved in Peruvianceramics more than 2000 years ago, aregraphic medical lessons proving theknowledge and skill of pre-Columbianphysicians. These ceramic sculpturesillustrate an important chapter in thehistory of medicine. Literature cited Barton, R., J. Rees, C. McDougall, andG.Ellard. 1982. The Nose in LepromatousLeprosy: Bacteriological and Histo-pathological Studies of Patients Treatedwith Dapsone Monotherapy. Internation-al Journal of Leprosy. 50:58-67.Bernard, J.C., and C.A. Vazquez. 1973.Study of Sixty Necropsies. InternationalJournal of Leprosy, 4 1 :94- 101.Binford, C. . and D. Connors. 1976. Pathol-ogy of Tropical and Extraordinary Dis-eases. Washington, D.C.: Armed ForcesInstitute of Pathology.Bird J.B. 1962. Art and Life in AncientPeru. An Exhibition in Curator II, NewYork.Desikan, K.V..andC.K. Job. 1968. A Re-view of Postmortem Findings in 37 Casesof Leprosy. International Journal ofLep- rosy. 36:32-44.Enna.C.D. 1968. A Survey of Leprous De-formities in Ryukyu Island. InternationalJournal of Leprosy. 36:271-281.Kean, B.H., and M.E. Childrees. 1942. ASummary of 103 Autopsies of LeprosyPatients on the Isthmus of Panama. Inter-national Journal of Leprosy. 10:51-59. Zagreb Paleopathotofiy Symp. 1988 Nasal leishmaniasis and amputation in ancient Peruvian ceramics ? 101 Kumar, S.. K. Malik, B. Kuman, M.Singh, and R. Chakravarty. 1979. Respi- ratory System Involvement in Leprosy.InternalionalJournal of Leprosy. 47: IS-IS.Larco-Hoyle. R. 1938-1939. Los Mochi- cas. Lima, Peru.Mareial Rojas. R.A.. and J.M. Kissane.1985. Mucocutaneous Leishmaniasis. InJ.M. Kissane, ed.. Anderson's Pathol-ogy, 411-412. St. Louis: C.V. Mosby.Mason. J. A. 1957. The Ancient Civilizationof Peru. IHamiondsworth. Middlesex):Penguin Books.Milsuda. K., and M. Ogawa. 1937. AStudy of One Hundred and Fifty Autop- sies on Cases of Leprosy. InternationalJournal of Leprosy. 5:53-60.Ortner. D.J.. and W.J.G. Putschar 1981.Identification of Pathological Conditionsin Human Skeletal Remains. Smithso-nian Contributions to Anthropology,28:176-180. Washington, DC: Smith-sonian Institution Press.Powell, S.C, and L.L. Swan. 1955. Lep- rosy: Pathologic Changes Observed inFifty Consecutive Necropsies. AmericanJournal of Pathology. 31:1131-1148.Sawyer, A.R. 1966. Ancient PeruvianCeramics. The Nathan Cummings Col-lection. New York: The MetropolitanMuseum of Art.Tello, J.C. and X.T. Mejia. 1960. Chavin.Cultura Matriz de al Civilizacion And-ina. Lima, Peru: Imprenta de la Univer-sidad de San Marcos.Urteaga-Ballon, O. 1968. Interpretation ofSe.xuality in the Ceramic Art of AncientPeru. Lima. Peru: Museo de Pal-eopatologia. Hospital "2 de Mayo." Figure 19. Prosthesis of the leg. Fourth stage. Patient is testing prosthesis apparatuswith hand opposite to amputated leg. Mochica culture, ceramic. Lima. Peru.Figure 20. Prosthesis of the leg. Fifth stage. Prosthesis apparatus attached topatient's left leg. Mochica culture, ceramic. Lima, Peru.Figure 21 . Prosthesis of the leg. Last stage. Patient is walking with help of a caneand prosthesis is attached to his left leg. Mochica culture, ceramic. Lima, Peru.Figure 22. Prosthesis of right arm. Patient was a blind man who had a prosthesisattached to his right arm. Mochica culture, ceramic. Lima, Peru. Zagreb Paleopathology Symp. 1988 Population Studies Temporal variation in femoral cortical thicknessof North American Plains Indians Douglas W. Owsley Oortical bone growth during periodsof juvenile gain and later adult loss hasbeen documented in long-term studiesof populations in Central and NorthAmerica (Gam 1970). Several vari-ables aft'ect tubular bone cortical thick-ness including age, sex, and nutrition.Changes in the bone envelope aresurface-specific and reflect the com-bined response of subperiosteal apposi-tion and endosteal resorption or apposi-tion.Simple malnutrition slows the rate ofbone growth and can lead to the forma-tion of less bone (Gam 1970,1972).Subperiosteal growth depends more on caloric sufficiency, protein seems to beless of a limiting nutrient. The effect ofprotein-energy malnutrition on corticalthickness is seen primarily on the innerbone surface. Endosteal resorption in-duced by kwashiorkor or marasmus canreduce the cortical wall to a thin shellwith an enlarged medullary cavity. Asmuch as 40% of the preformed bonecan be lost, even though the externalbone size remains relatively unaffected(Gam 1970; Gam et al. 1964,1969).Recovery-related catch-up growth orsurface repair through endosteal re-placement is limited (Gam 1966).Although most studies of corticalbone mass have focused on the living,these observations can be applied to theanalysis of archeological samples. Bio-archeological interpretations of pastsubsistence patterns have used corticalbone growth and thickness as an indica-tor of nutritional status (Cashion 1987;C(X)k 1979; Huss-Ashmore 1978; Zagreb Paleopathology Symp. 1*^88 Hummert 1983; Hummert and VanGerven 1983; Keith 1981; Owsley1985). Cashion (1987) and Owsley(1985) have reported age-controlledadult femoral midshaft cortical thick-nesses in temporally sequential NorthAmerican Arikara Indians of SouthDakota. Comparison of bone cortexdata for villagers representing three ar-cheological variants of the Plains Vil-lage Coalescent Tradition (Extended.A.D. 1550-1675; Post-Contact, a.d.1675-1780; and Disorganized, a.d.1780-1845) revealed statistically sig- nificant differences. Relative to the ear-lier Extended Coalescent and later Dis-organized Coalescent samples, thePost-Contact Variant sample showedmore cortical bone, presumably reflect-ing greater success in meeting village nutritional needs.This presentation examines the his-torical patterning of these temporal dif-ferences. Specific objectives are to de-fine the surface-specific nature of thedifferences reported between archeo-logical variants and to apply greatertemporal control using chronologicalperiods of shorter duration. Corticalthickness is a composite measure deter-mined by both the medullary cavity andthe total subperiosteal diameters. Arechanges in cortical thickness caused bychanges in only one or both of thesedimensions? Greater temporal controlwas made possible by obtaining datafor related sites and by sorting thislarger data base into smaller temporal units representing Late Prehistoric(A.D. 1600-1650), Eariy Protohistoric (1650-1740), Late Protohistoric(1740-1795), and Historic (1795-1832) period sites. Comparison ofthese four samples provides a clearerrepresentation as to the timing of corti- cal bone change during the Post-Contact period. An appreciation of thistiming is essential for understandingthe nutritional impact of contact-relatedhistorical events. Materials and methodsSample sizes and approximate dates ofthe 12 archeological sites included inthis analysis are presented in Table 1 . Inorder to avoid age-related cortical boneinvolution, the analysis was limited tofemora of young adults aged 16-35years, giving a total of 1 10 males and134 females. The bones were x-rayedin a standardized posterior-anterior pro-jection using a Kodak single lanex, finescreen X-omatic cassette. Only bonesin good condition were measured withpreference given the left side when available.Two midpoint cross-sectional obser- vations, total subperiosteal diameter(T) and width of the medullary cavity(M), were measured with a Helios dialcaliper to 0.1 mm (cf. Gam 1970).Three composite variables were de-rived from these measurements: corti- cal thickness (C), Nordin's Index (NI),and cortical area (CA). Cortical thick-ness was calculated as C = T ? M. Thevalue C represents the combined or netthickness of the medial and lateral walls. Nordin's Index (NI) or score was105 106 ? Douglas W. Owsley determined as Nl = C/T. This score isessentially two-dimensional and de-scribes the proportion of the total width attributed to the cortex. Cross-sectionalarea measurements were calculated asCA = 0.785 {T- - M=) (Gam 1970).This procedure assumes that the femurhas an approximately circular cross-sectional geometry in both the endo- steal and subperiosteal surfaces. Theassumption of a cylindrical shape is notnecessarily valid for the femur (VanGerven et al. 1969). Nevertheless, it is useful to consider cortical area as an-other indicator of bone status becausethis value represents absolute bonemass and potential calcium reserves (J.Dequeker, pers. comm.). As judgedfrom studies based on the second meta-carpal, cortical area shows the highestcorrelation with the ash content of thebone relative to the other measurementsand indices (Dequeker 1976). Max-imum femoral lengths (ML) were mea-sured on the radiographs using a metric ruler. Sample differences were evalu-ated using the general linear modelsanalysis of variance statistic presentedinSAS(1985). Results Sample means and standard deviations are presented in Table 2 by sex for eachof the four time periods. The means for cortical thickness and Nordin's Index are illustrated in Figures 1 and 2. Re- sults of the analysis of variance com-parisons by sex and time period are given in Table 3. As expected, sex dif-ferences are highly significant for thethree primary variables (i.e., M, T,ML) and also for cortical thickness and area, but not for Nordin's Index. Tem-poral differences are evident in eachvariable with the exception of max-imum length. The femoral lengths ofthese four samples are similar. In con- Table 1. Archaeological sites, sample sizes and time periods Site Femoral cortical thickness of North American Plains Indians ? 107 trast, marked sample differences arepresent in the amounts of cortical bone,as measured by the variables C. Nl andCA. The separate patterns reflected bymale and female measurements revealmarked correspondence. Mean valuesfor C and Nl for the Early Protohistoricperiod represent the high peaks for thistime series. Cortical thickness in-creased in both sexes during the transi-tion from the Late Prehistoric to theEarly Protohistoric period. Thesegains, however, were only temporaryand not sustained in the more recenttime periods. Later samples have re-duced cortical thicknesses. Both sexescorrespond in this trend, althoughfemales reveal the most dramatic loss oftubular bone.Sample differences in C and Nl re-flect net changes in both the medullarycavity diameter and the total sub-periosteal diameter. In females, me-dullary widths decreased during theEarly Protohistoric period. Late Pro-tohistoric and Historic period femalevalues returned to the Late Prehistoricaverage diameter and then greatly sur-passed this base, more closely approx-imating the larger diameters of males.Males during the Late Protohistoric andHistoric periods are characterized bylarger medullary cavity diameters thanfound decades earlier in Arikara popu-lations. Total subperiosteal diametersalso show temporal change with meanvalues for T increasing through time,especially in males. In terms of estimat-ed cortical areas, these small increasesin T diminish the effect of the linearincreases in M, the smaller diameter. Inboth sexes, calculated cortical areasshow the largest increase with the tran- sition from the Late Prehistoric to theEarly Protohistoric period. Because ofthe increase in T, cortical areas con-tinue to increase through the Late Pro-tohistoric period, followed by declineduring the early Historic period. In themost recent period, male and female cortical areas, although approachingthe early 17th century base line (espe- cially in females) are still higher thanduring the Late Prehistoric Period. 1500- - I4O0-. liOO-. 1200..mm FEMALES ?MALES LATEPREHISTORIC EARLYPROTOHISTORIC LATEPRerOHISTORIC HISTORIC Figure I . Femur midshaft cortical thickness by time period 0.57 . 0.56 055 .. Q54 .. 0.53 .. 0.52 . Oil .. 050 0.49 .. 0.48 0.47 Nl FEMALES MALES -I-LATEPREHISTORIC EARLYPROTOHISTORIC LATEPROTOHISTORIC HISTORICFigure 2. Temporal variation in Nordin's Index Zagreb Paleopathology Symp. 1988 108 ? Douglas W. Owsley Table 3. Two-factor analysis of variance of femurmeasurements by time period and sex Variable Souxe DF M NI CA ML Sum ofsquares PR>F ModelTimeSexInteractionErrorTOTALModelTimeSexInteractionErrorTOTAL TOTALModelTimeSexInteractionErrorTOTALModelTimeSexInteractionErrorTOTALModelTimeSexInteractionErrorTOTAL 73132362437313236243Model 7Time 3Sex 1Interaction 3Error 236243731323624373 13236 7313203210 226.6189.8139.0417.49748.57975.18495.6456.23202.7815.35632.761128.40144.6242.2563.876.89622.45767.07 0.110.090.000.020.80 0.91443280.8339578.65207997.5312656.08697817.91243 1141098.7478253.131552.6443241.22852.1378320.04156573.17 10.219.4412.311.84 26.416.9975.631.91 7.835.3424.210.87 4.488.430.081.49 21.424.4670.341.43 28.981.34112.080.74 0.00010.00010.00050.14 0.00010.00020.00010.13 0.00010.0010.00010.46 0.00010.00010.780.22 0.00010.00450.00010.24 0.00010.260.00010.53 NOTE: Sums of squares for time period, sex and interaction areType III. For variable abbreviations see Table 2. The interpretation of the overall pat-terns revealed by the variables C and NIand CA offers insight into the nutrition- al status of the post-contact Arikara.Specific reference to the archeologicaland ethnohistorical records helps clarify the historical events that affectedfood resources and reserves. Discussion The period after Euro-American con-tact was one of dramatic change.Arikara villages were located along theflood plain and lower terraces of theMissouri River valley (Lehmer 1971).Their mixed subsistence strategy wasbased on the gathering of wild plants,the cultivating of com. beans, squash,and sunflowers, trading, and hunting,especially of bison. Initially, their war- riors controlled activities on the river.Because of their ideal geographic loca-tion, the villagers actively participatedin intertribal exchange networks, reap-ing profits as middlemen betweengroups bringing aboriginal and Euro-pean trade materials from the easternwoodlands and others in the southernPlains and the southwest (Ewers 1955;Orser 1984; Wood 1980). This tradenetwork had its roots in the Prehistoricperiod. Following contact, the tradi-tional pattern expanded to include themovement of horses and Europeangoods. The Arikara intensified theirhorticultural activities during the earlycontact period to produce surpluses forexchange.The early contact period before 1 750has been described as a prosperous and stable period for the Arikara as re-flected archeologically in the numberand sizes of their villages and associ-ated midden deposits. Cache pit sizeand number increased during thisperiod suggesting increased hor-ticultural productivity (Lehmer andJones 1968). Some evidence also sug-gests that shifts in climatic conditionsproduced perceptible differences in thearcheological patterns of ExtendedCoalescent and Post-Contact Coales-cent sites: Zagreb Paleopathology Symp 1988 Femoral cortical thickness of North American Plains Indians ? 109 The Extended Coalescent settlementpattern of small villages occupied foronly a short time may represent a re-sponse to marginal economic condi-tions, which in tum were the productof a less favorable climate. . . .Bryson has suggested (Baerreis andBryson, 1965) that the Neo-Borealconditions were modified somewhatduring the first half of the 18th cen-tury. The larger and more permanentPost-Contact Coalescent settlementsin South Dakota may represent a re-sponse to this improvement in cli-mate. (Lehmer 1971:128)Late 1 7th and early 1 8th century popu-lations in general were well off. As re-flected by increased cortical thicknessand cortical area, the transition fromthe Late Prehistoric to the Early Pro-tohistoric was marked by a positivechange in nutritional status. A culmina-tion of factors insured greater reservesand diversity of resources that bufferedthe villages against lean times. Thesefactors included agricultural inten- sification to acquire surpluses for tradeand increased availability of meat ob-tained through hunting and trade.Horses, first brought to the valleyfrom the southwest, circa 1739, were avalued commodity in the middlemantrade, both as an object of trade and aspack animals. Given the lag time be-tween their introduction, initial use aspack animals, and later use for riding,the impact of the horse on the Ankaraeconomy would have been most signifi-cant after 1750 (D.J. Blakeslee, pers.comm.; Ewers 1955). Theoretically,horses made it easier to locate and killwild game and to transport larger quan-tities of meat to the village than possi-ble during the prehistoric period whendogs were used for this purpose (Holder1970). The acquisition of the horse,with a corollary increase in high-quality protein in the diet, has been in-terpreted as a primary reason why Post-Contact Coalescent villagers show in-creased femoral cortical thickness rela-tive to their late prehistoric ExtendedCoalescent antecedents (Cashion 1987;Owsley 1985). Yet, as apparent in this more finely graded temporal analysis,the Late Protohistoric period (1740-1795) was not accompanied by dramat-ic increases in femoral cortical thick- ness. In fact, a subtle reverse occurs.Medullary cavity diameters increasedmarkedly and mediolateral corticalthicknesses began to drop. In contrast, cortical areas did increase slightly be-cause of the larger values for T. Al-though this apparent inconsistency isnot easily interpreted, it is clear that themajor change (improvement) in Post-Contact period nutritional status pre-ceded the arrival of the horse. Any po-tential nutritional benefits derived fromuse of the horse were less significant.Later effects of Euro-American con-tact were negative and disruptive. Dis-organized Coalescent villages sufferedhigher levels of morbidity, populationlosses from disease and warfare, andsociocultural deterioration. "Between1738 and 1845, there was considerableinstability of population marked by vil-lage abandonment and relocation"(Ramenofsky 1987:104). Catastrophicpopulation losses followed the intro-duction and diffusion of acute infec-tious diseases, including cholera, mea- sles, smallpox and whooping cough(Lehmer 1971; Ramenofsky 1987;Trimble 1979,1985). Moreover, inter-tribal conflict escalated as militantnomadic groups moved into the middleMissouri region after being pushed outof the eastern woodlands. Arikara rela-tions were poorest with the DakotaSioux, who arrived circa 1730-1740(Owsley et al. 1977; Smith 1980). TheSioux placed increasing pressure on theArikara as conflict over bottom lands,which provided protection during theharsh winters, and competition fortrade booty and the yield from theArikara gardens intensified. The periodof most intense warfare with the Siouxdates to the historic period after 1790(D.J. Blakeslee, pers. comm.). Tru-teau's journal for his journey of 1794-1796, for example, mentions an ex-pected attack on an Arikara village by500 Sioux warriors well armed withguns(Truteau 1913-1914). The nutritional effects of thesechanges are clearly registered in in-creased medullary cavity diameters and net reductions in femoral cortical boneduring the early Historic period.Females seem to have been most af-fected by the stresses of this turbulent era. Although the direction and patternof change in bone mass are evident, es-timated cortical areas were still higherthan during the Late Prehistoric period.In summary, cortical bone thicknesshas proven to be a sensitive indicator ofchanges in Arikara nutritional statuscaused by environmental change. Incontrast, maximum long bone lengthhas not shown a significant response.The difference between these variablesmerits further consideration. More-over, future research must examinechanges reported for the variable T. To- tal subperiosteal diameters increasedthrough time, especially in males. Re-cent research concerning the geometricproperties of lower limb bone di-aphyses has shown the responsivenessof cross-sectional shape to differentmechanical loadings associated withbehavior such as more frequent running(Ruff 1987). Perhaps the increase in Twas a structural response to changes in activity level. In the future, we plan toconsider possible variations in geo-metric form by examining both the me-diolateral and anteroposterior axes anddirect measurement of cross-sectional area. Acknowledgments William Bass and Douglas Ubelakerkindly granted permission to examinethese collections. Archeological recov-ery was made possible by grants fromthe National Science Foundation andthe National Geographic Society. Don-ald Blakeslee and Daniel Rogers pro-vided archeological and cthnohistoricalinformation. Steve Symes, TerryZobeck, and Maria Cashion were re-sponsible for bone radiography and os-teometry. Suggestions concerning ana-lytical methodology were provided by J. Dequeker. Dana Bovee helped pre- Zagreb Paleopathology Symp. 1988 no* Douglas W. Owsley pare this manuscript. The illustrationswere provided by Ethan Ericksen. Datacollection and analysis were supportedby NSF BNS-8 102650 and BNS-8510588. Literature cited Baerreis. D.A.. and R.A. Br>son. 1965.Climate Episodes and the Dating of Mis-sissippian Cultures. The Wisconsin Anh- eologisl, 46(4).Cashion, M.A. 1987. A Diachronic Assess-ment of Stress Indicators in Three PlainsAmerican Indian Populations. M.A. the- sis. Department of Geography and An-thropology, Louisiana State University,Baton Rouge.Cook, DC. 1979. Subsistence Base andHealth in Prehistoric Illinois Valley: Evi-dence from the Human Skeleton. Medi-cal Anlhropolofiy, 4: 1 09- 1 24.Dequeker, J. 1976. Quantitative Radiology;Radiogrammetry of Cortical Bone. Brit-ish Journal oj Radiology, 49:912-920.Ewers, J.C. 1955. The Horse in Black-foot Culture. Bureau ofAmerican Ethnol-ogy Bulletin. 159. Washington, D.C.:Bureau of American Ethnology.Gam,S.M. 1966. Malnutrition and SkeletalDevelopment in the Pre-School Child. InPre-School Child Malnutrition: PrimaryDeterrent to Human Progress. 43-62. In-ternational Conference on Prevention ofMalnutrition in the Pre-School Child,1964. Washington. D.C.: National Acad-emy of Sciences.1970. The Earlier Gain and theLater Loss ofCortical Bone. Springfield,111.: Charles C Thomas.1972. The Course of Bone Gainand the Phases of Bone Loss. OrthopedicClinics of North America. 3:503-520.Gam, S.M., M.A. Guzman, and B.Wagner. 1969. Subperiosteal Gain andEndosteal Loss in Protein-Calorie Mal- nutrition. American Journal of PhysicalAnthropology. 30:153-156.Gam, S.M., C.G. Rohmenn, M. Behar, F.Vileri, and M.A. Guzman. 1964. Com-pact Bone Deficiency in Protein-CalorieMalnutrition. Science. 145:1444-1445.Holder, P. 1 970. The Hoe and the Horse onthe Plains: A Study of Cultural Develop- ment among North American Indians.Lincoln: University of Nebraska Press.Hummert. JR. 1983. Cortical BoneGrowth and Dietary Stress among Sub- adults from Nubia's Batn El Hajar Amer-ican Journal of Physical Anthropology.62:167-176.Hummert, JR., and DP. Van Gcrven.1983. Skeletal Growth in a MedievalPopulation from Sudanese Nubia. Ameri-can Jouriud of Physical Anthropology.60:471-478.Huss-Ashmore, R. 1978. Nutritional Deter-mination in Skeletal Populations. Ameri-can Journal of Physical Anthropology.48:407.Keith, M.S. 1981. Cortical Bone Loss inJuveniles of Dickinson Mounds. In D.L.Martin and M.P. Bumsted, eds.. Bio-cultural Adaptation. 64-77. Amherst:Department of Anthropology, Universityof Massachusetts.Lehmer, D.J. 1971 . Introduction to MiddleMissouri Archeology. Washington, D.C.:National Park Service.Lehmer. D.J., and D. Jones. 1968. ArikaraArchaeology: The Bad River Phase.River Basin Surveys Publications in Sal-vage Archaeology. 1. Washington, DC:Smithsonian Institution Press.Orser, C.E., Jr. 1984. Trade Good Flow inArikara Villages: Expanding Ray's Mid-dleman Hypothesis. Plains Anthropolo-gist. 29:1-12.Owsley, D.W. 1985. Post Contact PeriodNutritional Status and Cortical BoneThickness of South Dakota Indians. InM. Thompson, M.T Garcia, and F.J.Kense, eds.. Status. Structure and Strat-ification: Current Archaeological Recon-structions. 199-207. Calgary, Canada:Archaeological Association of the Uni- versity of Calgary.Owsley, D.W., H.E. Berryman, and W.M.Bass. 1977. Demographic and Osteologi- cal Evidence for Warfare at the LarsonSite, South Dakota. Plains Anthropolo-gist Memoir. 13:119-131.Ramenofsky, A.F 1987. Vectors of Death.Albuquerque: University of New MexicoPress.Ruff, C. 1987. Sexual Dimorphism in Hu-man Lower Limb Structure: Relationshipto Subsistence Strategy and Sexual Divi-sion of Labor. Journal of Human Evolu-tion. 16:391-416.SAS Institute Inc. 1985. User's Guide: Sta-tistics. Gary. N.C.: SAS Institute. Smith, G.H. 1980. The Explorations of theLa Verendryes in the Northern Plains,1738-43. Lincoln: University of Nebras-ka Press.Trimble, M.K. 1979. An EthnohistoricalInterpretation of the Spread of Smallpo.xin the Northern Plains Utilizing the Con-cepts of Disease Ecology. Lincoln: Na-tional Park Service Midwest ArcheologyCenter.1985. Epidemiology on the North-ern Plains: A Cultural Perspective. Col-umbia: Department of Anthropology,University of Missouri.Truteau, J.-B. 1913-1914. Journals ofJean-Baptiste Tmteau. The AmericanHistorical Review, 19:299-333.Van Gerven, D.P., G.J. Armelagos, andM.H. Bartley. 1969. Radiogenographicand Direct Measurement of Femoral Cor-tical Involution in a Prehistoric Mis-sissippian Population. American Journalof Physical Anthropology. 3 1 :23-38.Wood, W.R. 1980. Plains Trade in Pre-historic and Protohistoric Intertribal Re-lations. In W.R. Wood and M. Liberty, eds.. Anthropology of the Great Plains,98-109. Lincoln: University of NebraskaPress. Summary of audience discussion: Poro-tic hyperostosis is not a useful indicator for stress in this population since the avail- ability of bison prevented protein deficien- cy. Dental hypoplasia was absent and trans-verse (Harris") line frequency was notelevated. The pattern of native populationdecimation secondary to infectious disease shortly after contact with the early colonistsis absent in the Plains population reportedhere. The native population was large, andinitially the number of foreigners was low.In fact, the availability of horses enhancedthe bison harvest and trade ameliorated the effects of drought. Not until after 1750 didthe effects of the flow of eastern colonistsmoving to and through the Plains becomeapparent in the natives with a reduction inchild growth and increased frequency ofpremature delivery and the development ofan increase in both medullary diameter andthe subperiosteal diameter. It is clear thatNorden's Index is only of relative value. Zagreb Paleopathology Symp. 1988 Ethnohistorical accounts as amethod of assessing health, disease, andpopulation decline among Native Americans Marc A. Kelley Paleopathological inquiry, while typically relying on surviv-ing hard and soft tissues, can also benefit from a variety ofother sources. These include artistic representations (paint-ings, engravings, ceramics), coprolites, early medical texts(e.g., Greek, Roman, Chinese) and, as in this study, eth-nohistoric accounts. These accounts, when used in conjunc-tion with skeletal samples, not only provide meaningful in-sight into disease patterns present at time of contact betweentwo cultures, but also record natives' accounts of afflictionsand treatments existing prior to contact. I shall focus on theContact and early Historic periods of New England to dem-onstrate the utility of this approach. European contact with New England natives As any American historian knows, the landing of thePlymouth Pilgrims in 1620 was preceded by more than 120years of exploration, trade, Indian abduction into slavery,and foiled attempts at settlement on New England soil. Table I lists the official voyages from Europe, as well as some ofthe unofficial expeditions. The actual number of unofficialjourneys will never be known, but no doubt well exceeds thedocumented trips.From an epidemiological point of view, certain events dur-ing the exploratory period deserve closer attention. Hundredsof fishing vessels were visiting areas south of Newfoundlandeach year during the second half of the 16th century (Fite andReese 1965; Brasser 1978). In 1602 Gosnold encounterednatives wearing pieces of European clothing and understand-ing a fair number of European words (Purchas 1625). Fiveyears later Popham and Gilbert attempted to establish a col-ony on the Maine coast (Winship 1968). This was abandoneda year later. In 1616 two different parties, headed by Vinesand Hawkins, respectively, wintered at coastal ItKations inMaine (Gorges 1658; Howe 1942). One member of theGorges party. Richard Vines, observed the natives to be suf-fering a plaguelike disease to which the English wereseemingly immune (Gorges 1658). A few years later large Zagreb Paleopathology Symp. 1988 tracts of New England were nearly void of inhabitants, thuspaving the way for the Plymouth Pilgrims. Chronology of epidemicsA close inspection of ethnohistorical documents suggeststhat the devastating plague arising in 1616 in New Englandwas preceded by several pestilences in the second half of the16th century. After an earthquake rocked New England in1638 the founder of Rhode Island, Roger Williams, ques-tioned the Narragansett elders regarding earlier earthquakesand found that they not only remembered previous earth-quakes but associated each one with an epidemic: The younger natives are ignorant of the like; but the eldersinform me that this is the fifth |carthquake] with these 4score years in the land: the first about three score and tenyears since: the second some 3 score and four years since,the third some 54 years since and the fourth some 46 since:and they always observe either Plague or Pox or some otherepidemical disease followed; 3, 4 or 5 years after the earth-quake. (LaFantasie 1988:159-160) While the earthquake/epidemic dualism may be a meta-phor of Algonquian speech, the existence of epidemics is not. According to the elders the date for these epidemics was1572 ? I year, 1578 ? 1 year, and 1597 ? 1 year. However,if the Narragansetts had been affected by four epidemics theirnumbers were surprisingly robust by the early 17th century.The so-called plague which began in 1616 continued atleast until 1619 (Cook 1973b), perhaps until l622(Winslow1841; Morton 1632), and swept away untold thousands ofIndians. Graphic accounts have been passed down to us byseveral explorers and settlers. Thomas Morton (1632:18-19), for example, described scenes near Boston as follows: They died on hcapes, as they lay in their houses and the liv-ing; that were able to shift for themselves would runncaway, and let they dy. and let there carkases ly above theIII 112 ? Marc A. Kelley Table l. European voyages to New England prior toA.D. 1620 Date Historical accounts in assessing paleopathology of Native Americans ? 113 Table 2. 114 ? Marc A. Kelley efficacy of providing simple attendance to the ill?namely,insuring bedrest, warmth, plenty of fluids and emotionalcomfort. Edward Winslow's account (1841 ) of his treatmentof the nearly dead Sachem Massasoit in 1623 is enlightening.The Sachem, in an advanced state of illness (suffering possi-bly from an intestinal virus) had lost his sight, his tongue hadswollen, and he suffered from dehydration. Winslow admin-istered some physick (which usually consisted of raisins,currants or other fruit), he then scraped the Sachem's tongueand was able to mix water with the physick. which Massasoitreadily consumed. Within a half hour or so, Massasoit wasimproving, as was his vision.So here we see that a man on the brink of death was aidedby the simple administration of water and fruit, not by anysophisticated medical technology. As Massasoit continued toimprove, Winslow graduated him to chicken broth, whichmade him stronger still. The colonists realized the value offluids and the danger of fatty foods during recovery fromsuch illnesses, but unfortunately the Indians did not. Duringhis recovery, Massasoit nearly died a second time by gorginghimself on fatty duck meat. As we know, Massasoit didsurvive and lived a long life, but thousands of other nativeslost their lives abruptly because of unattended simple needsof the sick.With this in mind, let us once again examine passagesfrom Governor Bradford's journal concerning Indian suffer-ing and lack of basic health care:And then being very sore, what with cold and other dis-tempers, they die like rotten sheep. The condition of thispeople was so lamentable and they fell down so generallyof this disease as they were in the end not able to help oneanother, no not to make a fire nor to fetch a little water todrink, nor any to bury the dead. But would strive as along as they could, and when they could procure no other meansto make fire, they would bum the wooden trays and dishesthey ate their meat in. and their very bows and arrows. Andsome would crawl out on all fours to get a little water, andsometimes die by the way and not be able to get in again.(1970:271, italics mine) This passage indicates that (1) a synergism existed be-tween smallpox and other distempers, which inevitably led tohigher mortality rates than otherwise expected, (2) mostmembers of a tribe were sick simultaneously, and (3) basichealth needs went unattended. The English eventually tookpity on the suffering Indians and tried to help them, but bythen, one suspects, it was too late. One additional factorwould have contributed to the natives' downfall: the psycho-logical despair and apathy associated with epidemic sick-ness. For example. In the 2()th century, outbreaks of virusesamong remote South American tribes lead to a fatalistic out-look among not only those affected, but the unaffected aswell. Had not the medical researchers intervened, mortalitylevels would certainly have been high. The differences between European and Indian strategiesfor health care are thus obvious, but can we attribute suchstaggering mortality rates among the Indians simply to healthcare differences? For example, it has been argued that theIndians possessed greater genetic susceptibility to Old Worldpathogens. While this may in small part be true, I believe ithas been greatly exaggerated by medical historians over thelast several decades. It is important to remember that, thoughnot so dramatically, smallpox, influenza, yellow fever, andtuberculosis claimed a steady toll of colonists each year.Such diseases were feared by both races. The possibilityexists that Indians lacked certain acquired immunities to OldWorld pathogens. Viral infections such as measles and small-pox confer lifelong immunity if the victim survives. Euro-pean immigrants were much more likely to have been ex-posed to such viruses in the high-density towns and cities ofEurope and thus be immune to subsequent outbreaks occur-ring in the New World. 1 remain unconvinced that Europeanspossessed an inherent genetic resistance to these viruses.Smallpox, for example, seems to have been imported fromAsia into Europe only a few centuries prior to exploration ofthe New World. It would seem unlikely that any appreciable natural selection could have occurred among Europeans dur-ing that interval.In effect, the bulk of evidence would suggest that while acertain amount of loss of life from imported disease wasunavoidable, the devastating epidemics suffered by Indianswere not necessarily inevitable. Case study: Life for mid- 17th centuryNarragansetts after the viral epidemics The recent discovery and excavation of a Narragansett ceme-tery dating between 1650 and the 1670s (see Robinson et al.1985 for additional background) provide us with an idealopportunity to examine the biosocial context of the epi-demiological transition to an endemic disease setting amongthese natives. This cemetery was located only three milesfrom where Richard Smith and Roger Williams had set up atrading post in 1637 or 1638. There is little doubt that theseIndians experienced frequent and sustained interaction withthe English settlers.Aspects of Indian acculturation included employment bythe colonists to build stone walls (Gookin 1792), the tendingof livestock and use of English mills for maize from the1640s onward (Cronan 1983; Lechford 1867; Williams1874), and the widespread detrimental consumption of alco-hol . This last factor was of suftlcicnt magnitude to prompt theRhode Island colonists to pass legislation prohibiting the saleof liquor to the natives at least five times during the 1650s(Bartlett 1856). The rich diversity of European goods buriedamong the 56 members coupled with skeletal evidence ofcertain chronic disease states provide further evidence of thiscoexistence. Zagreb Paleopalholofiy Symp. I9S8 Historical accounts in assessing paleopathology of Native Americans ? 115 The skeletal remains indicate an extraordinarily high fre-quency of skeletal tuberculosis with 30% of the cemeteryexhibiting lesions of the spine, ribs and/or hip (Kelley andRobinson in prep; Robinson etal. 1985; Kelley 1986). Sincenot all individuals with tuberculosis exhibit skeletal lesions,the number of individuals suffering from this infection musthave been considerably higher.The rise in tuberculosis rates among New England Indianswas noticed by some colonists even during the 17th century.In the 1690s Daniel Gookin made the following, rather re-markable statement: Sundry of those Indian youths dies, that were bred up toschool among the Knglish. The truth is, this disease is fre-quent among the Indians; and sundry die of it, that live notwith the English. A hcctick fever, issuing in a consump-tion, is a common and mortal disease among them. / knowsome . . . have attributed it unto the great change upontheir bodies, in respect of their diet, lodging, apparel, stud-ies; so much differentfrom what they wer inured to amongtheir own countrymen. (1792:173, italics mine)The association between altered lifestyle and elevated tu-berculosis rates is widely acknowledged today. Figure 1 de-picts the Rl-1000 burial ground plan. An interesting patternemerges when individuals with tuberculous lesions are col-ored in. Whether this represents disease spread within sever- al family households, or a flare-up of tuberculosis in thecommunity, or enhance chance distribution is uncertain.Williams's description of the Narragansett social practice of visiting the sick is perhaps insightful. He wrote:The visit of friends, and neighbours, a poore empty visitand presence, and yet indeed this is very solemne, unlesse it be in infectius diseases, and then all forsake them andflic, that I have often scene a poore house left alone in thewild woods, all being fled, the living not able to bury thedead: so terrible is the apprehensions of an infectious dis-ease, that not only persons, but the houses and wholetowne takes flight. (Williams 1643:210)Such a practice may have been a key element in postepidemicNarragansett decline. Crowding around or simply cohabitat-ing with a sick person who was perceived as not suffering aninfectious disease (which would almost certainly includechronic tuberculosis) could result in the pattern observed inFigure 1.In humans, tuberculosis occurs as an acute or chronicinfection caused by either Mycobacterium tuberculosis (hu-man form) or Mycobacterium bovis (bovine form). The hu-man form is primarily transmitted from person to person byinhalation of the bacilli into the lung. This pulmonary infec-tion, which is often contracted during infancy and childhood,may spread rapidly to other portions of the body or becomeencapsulated and remain dormant for years or decades. Theextreme prevalence of tuberculosis was (and continues to be 0' <9 6>, Rl 1000 ePLAN OF BURIALS ^ 6^ oe & & < /' "x* / ?, Oltplacid burlolt"^ ' '> ^. / 1,5.6,7,53-57 Figure 1 . Rl-1000 burial ground plan. Shaded areas indicateindividuals displaying skeletal manifestation of tuberculosis. in certain areas of the world today) due to such factors asmalnutrition, overcrowding, war. social upheaval, poverty,alcoholism, and smoking (Lester 1981:972; Burnet andWhite 1975:217). At least some of these conditions werepresent in mid- 17th century southern New England Indiancommunities.Certainly other infectious diseases were taking a tollamong the Narragansetts. Pneumonia and dysentery (gas-troenteritis), while not leaving any telltale lesions on thebones, are noted in early accounts (Williams 1643) and in-deed are still a serious problem in American Indians today.Evidence for a treponemal infection at Rl-1000 was noted inone young adult female. The nasal cavity is extensively de-stroyed and the young woman's hands were placed imme-diately in front of her face?a pattern not seen in the otherburials. Williams (1643) reported that the Narragansett "hot-house" was used in treating the French disease (i.e., syph-ilis). Finally, one all-pervasive, chronic disease present atRl-1000 was severe dental disease (see Kelley et al. 1987 fordetailed discussion).Each of these chronic conditions was capable of directly orindirectly claiming human life and no doubt contributed tothe steady attrition of New England Indians in the mid- 17th Zagreb Pateopathotogy Symp. 1988 116 ? Marc A. Kelley century. However, this attrition was not nearly so dramatic ordevastating as were the eadier viral epidemics. Conceivablysuch native American groups eventually would have reachedan equilibrium and the population would have begun to growagain. This scenario, however, apparently did not fit into thecolonists' larger plan. Those who avoided death from mi-crobes would next contend with guns and swords. It is widelyacknowledged that warfare tactics differed for Europeans andIndians. The more ritualistic and symbolic style of warfareoften practiced by Native Americans prompted RogerWilliams to write: Their warres are farre Icssc bloudy. and devouring then thecmell warres of Europe; and seldomc twenty slaine in apitcht field: partly because when they fight in a wood everytree is a bucklar. When they fight in a plaine. they fightwith leaping and dancing, that seldome an arrow hits, andwhen a man is wounded, unless he that shot follows uponthe wounded, they soone retire and save the wounded: andyet having no swords, nor guns, and all that are slaine arecommonly slain with great valour and courage: for the con-querour ventures into the thickest, and brings away thehead of his enemy. (1643:204)The Narragansetts objected to the English warfare style,according to John Underbill (1638), because it "slays toomany men." Furthermore, the natives had traditionallyspared the lives of women and children, a practice not at allobserved by the Dutch and English. While Indians slain dur-ing battle and massacres obviously contributed to populationdecline, the more profound blow occurred in the aftermath ofhostilities?more specifically, the colonial practice of de-stroying com fields and supplies. The result, of course, wasfamine and more disease?thus providing the rationale forincluding both disease and warfare in this report. An exam-ination of Cook's tabulation of Indian losses during KingPhilip's War (1675-1676) illustrates the magnitude of sec-ondary losses (Cook 1973a:21): 1 ,250 killed in battle625 died of wounds3 ,000 died of exposure and disease 1 ,000 sold as slaves2,000 permanent refugees7,875 total lost3,875 remaining 1 1 ,600 TotalFor the Narragansetts. who had been relatively fortunatewith regard to introduced disease. King Philip's War effec-tively reduced them to a remnant population. Table 4 high-lights the fate of 17th century Narragansetts by comparingthem to McElroy and Townsend's (1985) medical model for19th century Canadian Inuit natives. This table lists thestages of contact on one axis and the epidemiologic, demo-graphic, nutritional, and health care subsystems on the other axis. Stage 1 is identical for each group. Stage II remains quite similar, but Stage III departs radically. Instead of popu-lation rebound, we see heavy warfare losses and subsequentfamine, exposure, and disease. In addition, there was essen-tially no governmental assistance in the 1 7th century. In effect, 17th century natives had to face a deadly double-edged sword of epidemics and warfare. To sum, the use of ethnohistorical records can prove en-lightening in our effort to better understand the health pat-terns of early human populations. It is imperative to remem-ber, however, that clinical descriptions can be vague (as wellevidenced by the long-enduring controversy of syphilis ori-gins based on written records). Nonetheless, many diseasesare much less controversial (e.g. , dysentery, measles, small-pox) and the ethnohistoric record can provide insight in suchcases whereas the skeletal remains cannot. Where circums-tances permit, this author recommends careful scrutiny and utilization of these alternate resources. Literature cited Bartlett, J.R. 1856. Records of the Colony of Rhode Island andProvidence Plantations in New England, vol. I (1636-1663).Providence. R.I.: Greene and Brother.Bradford, W. 1970. Of Plymouth Plantation 1620-1647. NewYork: Alfred A. Knopf.Brasser, T.J. 1978. Early Indian-European Contacts. In B.C. Trig-ger, ed.. Handbook ofNorth American Indians, vol. 15, North- east. Washington, D.C.: Smithsonian Institution Press.Burnet, M., and D.O. White. 1975. Natural History of InfectiousDisease. 4th edition. New York: Cambridge University Press.Cook, S.F. 1973a. Interracial Warfare and Population Declineamong the New England Indians. Ethnohistory. 20:1-24.1973b. The Significance of Disease in the Extinction of theNew England Indians. Human Biology. 45:485-508. 1 976. The Indian Population of New England in the Seven-teenth Century. Publications in Anthropology, vol. 12. San Fran- cisco: University of California Press.Cronan. W. 1983. Changes in the Land: Indians. Colonists, and theEcology ofNew England. New York: Hill and Wang.Cushman, R. 1622. Cushman's Discourse. In A. Young, cd..Chronicles ofthe Pilgrim Fathers of the Colony ofNew Plymouthfrom 1602-1625. Boston: C.C. Little and J. Brown.DeForcst, J.W. 1852. History ofthe Indians ofConnecticutfrom theEarliest Known Period to IS50. Connecticut Historical Society.Hartford, Conn.: W.J. Hammersley.Dermer, T. 1619. Letter to His Worshipfull Friend Samuel Purchas,Preacher of the Word, at the Hurcha a Little within Ludgate.London. In Purchas. vol. 19 (1905-1907). Glasgow: J. Mac-Lehose and Sons.Dobyns, H.F. 1983. TheirNumber Became Thinned: Native Ameri-can Population Dynamics in Eastern North America. Knoxville:University of Tennessee Press.File, E.D., and R. Reese. 1965. An Economic History ofthe UnitedSlates. Boston: Houghton Mifflin.Gookin, D. 1792 1 16931. Historical Collection of Indians of NewEngland. Massachu.selts Historical Society Collections, scries 1, vol. I. Zagreb Paleopathology Symp. 1988 Historical accounts in assessing paleopathology of Native Americans ? 117 Table 4. Comparative medical models 118 'Marc A. Kelley Gorges, F. 1658. A Briefe Narration of the Original Undertakingsof the Advancement of Plantations in Parts ofAmerica. London;E. Brudencll for N. Brook (Prince Soc. 1X90).Howe. H.F. 1942. Sources of New England Indian History prior to1620. Massachusetts Archeological Society Bulletin, 3:19-24.Hubbard, W. 1815. /I General History of New Englandfrom theDiscovery to 1680. Massachusetts Historical Society.Cambridge, Mass.: Hillard and Metcalf.James, S.V., ed. 1963. Three Visitors to Early Plymouth. Letterfrom E. Altham to Sir Ed. Altham (Sept. 1623). Massachusetts:Plymouth Plantation.Jameson, F. , ed. 1910. John.son's Wonder Working ProvidenceI62H-I65I. New York: Charles Scribner's Sons.Josselyn, J. 1674. An Account of Two Voyages to New England.London: Printed for Giles Widdons.Kelley, M.A. 1986. Disease, Warfare and Population Declineamong Seventeenth Century New England Indians. Paper pre-sented at Peoples in Contact: Indians and Europeans in the Seven-teenth Century, Haffenraffer Museum of Anthropology, Bristol,R.l.,Sept. 27.Kelley, M.A.. T.G. Barrett, and S. Saunders. 1987. Diet, Dental,Disease and Transition in Northeastern Native Americans. Manin the Northeast. 33: 1 1 3- 1 25 . Kelley, M.A., and P.A. Robinson. In prep. Coping with Change:The Effects of European Colonization on the Narragansett Indi-ans in the Seventeenth Century.Krochmal, A., and C. Krochmal. 1973. A Guide to the MedicinalPlants of the United States. New York: New York Times BookCo.LaFantasie, G.W. Correspondence of Roger Williams, vol. 1.Hanover and London: University Press of New England.Lechford , T. 1 642 . Plain Dealing or Newsfrom New England. J. H . Trumbull, ed. (1867). Boston: J.K. Wiggin and William ParsonsLunt.Lester, W. 1981. Tuberculosis. In A.l. Braude. cd. . Medical Micro-biology and Infectious Disease, 971-980. Philadelphia: W.B.Saunders.McElroy, A., and P. Townsend. 1985. Medical Anthropology inEcological Perspective . Boulder, Colo.: Westvicw Press.McManis, D.R. 1972. European Impression of the New EnglandCoast. 1497-1620. Chicago: University of Chicago Press.Morton, T. 1632. The New English Canaan or New Canaan.Amsterdam: J.F. Star.Purchas, S. 1625. Hakluytus Posthumus or Purchas His Pilgrimes:Contayning a History of the World in Sea Voyages and LcmdeTravells by Englishmen and Others. 20 volumes (1905-1907).Glasgow: J. MacLehose and Sons.Robinson, PA.. MA. Kelley, and P.E. Rubcrton. 1985. Prelimin-ary Biocultural Interpretations from a Seventeenth-Century Nar-ragansett Indian Cemetery in Rhode Island. In WW. Fitzhugh, ed., Cultures in Contact: The Impact of European Contacts onNative American Cultural Institutions AD. 1000-1800. 107-130. Washington, D.C.: Anthropological Society of Wash-ington.Smith, J. 1631 . Advertisements for the Unexperienced or the Pathway to Erect a Plantation. Massachusetts Historical Society Col-lection, series 3, 3:1-53. Spicss, A.E., and B.D. Spiess. 1987. New England Pandemic of1616-1622: Cause and Archaeological Implication. Man in theNortheast. 34:71-83.Tantaquidgeon, G. 1925-26. Mohegan Medicinal Practices. 4.hlAnnual Report of the Bureau of American Ethnology. Wash-ington, D.C.Thomson , W. A . R . , ed . 1 978 . Medicinesfrom the Earth : A Guide toHealing Plants. Maidenhead, U.K.: McGraw-Hill.Underbill, J. \6iS. Newsfrom America or. a New and ExperimentalDiscoverie of New England. London: printed by J.O. for PeterCole.Vogel, V.J. \'iH). American Indian Medicine. Norman: Universityof Oklahoma Press.White, J. 1630. The Planters Plea, or the Grounds of PlantationsExamined, and the Usual Objections Answered. London: W.Jones.Williams, R. 1643. A Key into the Language of America: Or AnHelp to the Language of the Natives in That Pan of America,Called New England. Publications of the Narragansett Club.1874. In JR. Bartlett, cd.. Letters (1632-1682) ofRogerWilliams. Publications of the Narragansett Club.Winship, G. 1968. Sailors Narratives of Voyages along the NewEngland Coast 1524-1624. New York: B. Franklin.Winslow, E. 1841. Winslow's Relation "Good Newes from NewEngland: . . . (1624). In A. Young, ed.. Chronicles of the Pil-grim Fathers ofthe Colony ofPlymouth, from 1602 to 1625, 269-376. Boston: C.C. Little and J. Brown.Winthrop, J. \90S [1630-1649]. History ofNew England, vol. I.New York: Charles Scribner's Sons.Young, W. 1846. Chronicles of the First Planters of the Colony ofMa.s.sachusetts Bayfrom 1623-1636. Boston: C.C. Little and J.Brown. Summary of audience discussion: Tuberculous involvement inone-third of an archeological population is an unprecedented rate.The author of this study defended his diagnosis on the basis ofincluding only lesions characteristic of tuberculosis seen in thespine, hip and ribs. Costal periostitis in an appropriate pattern re-flects the presence of empyema of tuberculous origin since it could not be identified on x-ray in 400 modern patients with pyogenicpneumonia. Such a study, however, needs to be carried out onmodem patients with pyogenic empyema. Recognition of charac-teristic, empyema-induced tuberculous costal periostitis in an ar-cheological population will usually double the tuberculous frequen-cy predicted by the more traditional measures. Known closeinteraction between these natives and the colonists makes highcr-than-usual frequencies of tuberculosis plausible. Since historicalrecords in earlier periods may be influenced by imprecision ofdiagnostic tenninology and even by political influences (derivingfrom administrative, self-serving reports as may have occurred dur-ing the South African colonial era), such evidence should not beused in isolation but may, as in this case, be considered supportive. Zagreb Ptileopatholiiay Symp. t988 Interpretation of infectious skeletal lesionsfrom a historic Afro-American cemetery Jerome C. Rose and Philip Hartnady Afro-American history is a complexsubject which has engendered consider-able interest and numerous debates in-volving not only historians, but an-thropologists and demographers as well. During Reconstruction (1865-1877) the lives of Afro-Americanswent through numerous changes wherethe former plantation slaves undertookthe transition from a life dictated byothers to one of self responsibility. Thistransition was aided by temporaryprovision of housing, food, and medi- cal care by the occupying Union mili-tary forces and other agencies both gov-ernment and private (Stampp 1965). Incontrast to the well-documented slav-ery era, health-related data for both theReconstruction and post-Reconstruc-tion (1878-1930) periods are scarceand, at times, of questionable quality.No geographically specific understand-ing of Afro-American demographicprocesses between 1 860 and 1 930 canever be achieved because of the ques-tionable quality of the 1870, 1890, and1920 censuses (Farley 1970:3). Thisscarcity of both demographic and dis-ease data can be attributed primarily tothe lack of record keeping and inade-quate census procedures resulting fromthe turmoil of "carpetbag rule" in theformer Confederacy and a continuationof this situation for Afro-Americanswith the establishment of legalized seg-regation during the post-Reconstruc-tion period. Until recently, the skeletalremains of people from this time periodhave been largely unavailable. Yet,skeletal analysis can provide informa- Zagreh Paleopaihology Symp. IVHH tion critical to understanding the condi-tions of life and health during this his-toric period.The analysis of skeletal remains col-lected during the relocation of CedarGrove (3LA97), a rural Afro-Americancemetery in southwest Arkansas, is ide- ally suited for addressing issues ofpostemancipation health. Demograph-ic and paleopathological data are usedto test the imperfect historic reconstruc-tions of postemancipation life and pro-vide a more detailed picture, at least forthis sample, of diet, health, and thegeneral quality of life. The analysis ofthe Cedar Grove skeletal sample alsoprovides an opportunity to test the va-lidity of paleodemographic and paleo-pathological interpretations by compar-ing them with those derived fromcensus data and historic documents. Itis not uncommon for the utility of pa-leodemography to be called into ques-tion. For example, Bocquet-Appel andMasset (1982) contend that paleode-mography cannot provide a true or real-istic reconstruction of a populationusing skeletal data. Although this crit-icism has been clearly answered by anumber of authors (Buikstra andKonigsberg 1985; Van Gcrven and Ar-melagos 1983), the Cedar Grove dataare used to test the concordance of pa-leodemographic interpretations withthose derived from census data. Sim-ilarly, doubts have often been raisedconcerning paleopathology, in particu-lar the inaccuracies of lesion diagnosis(see Ubelaker 1982:344-345) and the utility of using skeletal lesions to recon- struct disease patterns (see Buikstra andCook 1980:439-440). Again, concor-dance between the paleopathologicalinterpretations and the historic litera-ture is tested with the Cedar Grove ma-terial. Materials and methods During the construction of a revetmentalong the Red River, the U.S. ArmyCorps of Engineers encountered whatwas thought to be a small historic ceme-tery and a prehistoric American Indianfarmstead. After determination of eligi-bility for nomination to the NationalRegister of Historic Places, the markedhistoric graves were relocated and theprehistoric site excavated by the Ar-kansas Archeological Survey. Duringthe excavation, an additional 104 un-marked grave outlines were located.Historic investigation established thatthis cemetery had been used by theAfro-American community associatedwith the Cedar Grove Baptist Church,which lost use of the cemetery when itwas covered by almost two meters of silt during the 1927 flood. After exten-sive negotiations and legal determina-tions, those 79 graves scheduled for de-struction by revetment constructionwere excavated, analyzed, and relo-cated to a new cemetery. The skeletalremains and all associated grave con-tents were excavated using standard ar-cheological techniques and analyzed in a field laboratory prior to reburial in anew cemetery plot. All archeologicaland osteological analyses were con-119 120 ? Jerome C. Rose and Philip Hartnady ducted in the field within portablebuildings brought to the excavation siteand used laboratory and photographicequipment brought from the Universityof Arlcansas campus. All skeletal mate- rials were washed, inventoried, andphotographed. Age for subadults wasdetermined using dental development(Schour and Massler 1941) and epi-physeal union (Krogman and Iscan1986:50-97). Age determination foradults used pelvic criteria. Each pubiswas scored using the Todd system withthe Brooks modification (as cited inKrogman and Iscan 1986:148-154),and the pubic cast system for males(McKem and Stewart 1957) and fe-males (Gilbert and McKem 1973). Theauricular surface age system employingboth textual and photographic descrip-tions of each stage was also applied(Lovejoy et al. 1985). Macroscopicallyobserved skeletal lesions were recordedusing the system adapted by Powell(1985:433-434). This system recordseach pathological lesion by a numericalcode, textual description, and color-coded drawings on a skeleton outlineprovided on the recording forms. Thefour-digit numerical code provides thefollowing information: type of lesion(i.e., resorptive, proliferative, trauma,and neoplasm), location on bone, ex-tent of lesion, and status of lesion (i.e.,active or remodeled). The textual de-scriptions and drawings provided clari-fication of the code for each lesion anda photograph was taken of each. Thenumerical code was entered, along withage and sex, into a computerized database for this analysis. Results Both historical and archeological evi-dence established that all excavated in-dividuals were interred between 1890and 1927. The 79 excavated graves pro-duced a total number of 80 individuals,as one grave contained two individuals(seven-month in utero twins). The ageand sex data (see Table 1) were ana-lyzed using an abridged life table fol-lowing the procedures of Swedlund andArmelagos (1976:63-64) and com- TabLE 1. Demography of the Cedar Grovehistoric cemetery Age Skeletal lesions from a historic Afro-American cemetery ? 121 parisons are made to model life tables(Weiss 1973:115-186). The most diag- nostic feature of the Cedar Grove de-mographic profile is the large propor-tion (55.0%) of individuals youngerthan 15 years, which is identical to that(55.3%) produced by model life table15.0-45.0 (Weiss 1973:118). Thismodel table is considered to be the best fit for the Cedar Grove demographicdata. The computed life expectancy atbirth for Cedar Grove is 14 years whichis only slightly below the 15 years pre-dicted by the 15.0-45.0 model life ta-ble. The only major difference betweenCedar Grove and this model life table isthe much higher proportion of individu- als less than one year of age at CedarGrove (27.5%) than predicted (5.4%)by the model table. However, whenthe large number of neonatal deaths(20.0%) are removed (i.e., skeletonsaged at birth or younger than birth), the resulting figure (7.5%) is comparable.The Cedar Grove skeletal series is mostremarkable for the extremely high rateof skeletal lesions; almost 90% of theentire sample exhibit at least one lesion,and the average is 12 per individual (to-tal lesions = 959). Five individuals areaged to younger than birth and probablywere premature stillboms. Each ofthese exhibit active systemic periostitisindicating uterine infections which maybe implicated in the premature births.Of the 1 1 neonates, 9 (81.8%) exhibitsystemic active periostitis with addi-tional lesions as follows: 4 (36.4%)with active cribra orbitalia, 3 (27.3%)with active endocranial periostitis, and5 (45.4%) with periostitis of the ribs.One neonate has no lesions, while asecond shows healed endocranial peri- ostitis. The 17 children between 3 and20 months of age display a lesion pat-tern comprising 23.5% craniotabes. Table 3. Percent healed osteolytic/prolifarative lesions by age in years Birth 122 ? Jerome C. Rose and Philip Hartnady be noted that we combined age groups11-19 and 20-29 years to facilitatecomparison by producing a sample size(9) approximately equal to the other agegroupings. Table 2 shows that both theprematures and neonates (grouped to-gether as aged at birth) have a high fre-quency of systemic proliferative le- sions. Virtually every component of theskeleton is impacted: cranium, ribs,bones of the arm, pelvis, and bones ofthe leg. Of particular interest is the high rate of endocranial involvement (38%).The fact that these lesions are so exten- sive, even on those individuals agedyounger than birth, strongly suggeststhat the infectious agent was contractedin utero. The patterning of lesions (i.e.,distribution among the bones of theskeleton) remains relatively stable be-tween birth and 10 months, but then,with the exception of the cranium and clavicle, the frequency of infectedbones declines. The fact that no healed cranial lesions are found on individualsof any age (Table 3) indicates that fewor none of those neonates and childrenwith cranial infections survived. Forexample, examination of infections ofthe calvarium (Figure 1) shows a de-cline with age and only two healed le-sions among those aged between 40 and49 years. This pattern is roughly similarfor all bones of the skull.The postcranial skeleton shows a slightly different pattern. Active le-sions of the arm bones drop steadilyfrom birth through 5 years and reoccur at sporadic low levels between 1 1 and39 years. This pattern can best be illus-trated by lesions of the radius (Figure2). The few healed infections of the armcan best be attributed to late-occurringinfections and not to survivorship of theinfected infants. The arm lesions sug-gest a bimodal pattern of origin with thefirst peak of active infections occurringbefore and at birth and the second oc-curring between 1 1 and 39 years.In contrast, the infectious lesions ofthe leg, especially the lower leg, show atrimodal distribution. Like the armbones, the active lesions of the leg archighest at birth, drop significantly be-tween birth and 10 months, exhibit a CEDAR GROVE CALVARIUM INFECTIONS Skeletal lesions from a historic Afro-American cemetery ? 123 124 ? Jerome C. Rose and Philip Hartnady This contract labor system sooncame to an end and the large plantationswere broken up into individual allot-ments, farmed by the Afro-Americansunder a sharecropping arrangement(i.e., a portion of all crops was turnedover to the landowner). The system ofadvancing loans for seed and supplies,which was commonly intnxiuced through-out the South, usually served to keepthe sharecroppers poor and in debt tothe landowners and merchants (Chris-tensen 1958). Conditions deterioratedfurther in 1888 when a rapid decline incotton prices left all southern Arkansasfarmers poor and in debt to the stores(Graves 1967:30). A further disasteroccurred in 1905 when the boll weevilarrived in southeast Arkansas and vir-tually wiped out the cotton crops, themajor source of cash income (Sylva1981:52). These deteriorating agrarianconditions stimulated the Euro-Ameri-can backlash which wiped out virtually all the social gains of the Reconstruc-tion period. The process of segregationand political disenfranchisement beganwith the passage of new discriminatoryvoting laws and the first Arkansas seg-regation law, the separate coach act, in1891 (Graves 1967:61-94). These po-litical and social changes, in combina-tion with the farm price crisis, shouldhave seriously and adversely impactedAfro-American diet and health in theCedar Grove area.Sylva identifies a decline in the Afro-American population in southwestArkansas during this period and at-tributes it to outmigration ( 1 98 1 : 1 6). Incontrast, Farley observes a nationaltrend of significant slowing of the Afro-American population growth between1880 and 1940 (1970:3). He notes thatAfro-American women who beganchildbearing before 1850 and survived until menopause produced an averageof seven children and less than \Q% ofthese women produced no children.Women born between 1900 and 1920not only had the lowest fertility beforeor since, but 30% never had a child andthose that did had fewer (Farley 1970: 3). These data suggest that a biological crisis occurred for the entire Afro-American population at the turn of thecentury. This trend was so noticeablethat Holmes (1937) prepared a mono-graph predicting the disappearance ofAfro-Americans.The population decline is to be at-tributed not only to decreased fertility,but also to greatly increased mortality.Urban Afro-American life expectancy at birth in 1900 was 33 years for malesand 35 years for females (Farley1970:61). In 1900 the Afro-Americanmortality rate was 3.02%, nearly twicethat of Euro-Americans with 1.73%(Holmes 1937:40; Kiple and King1981:188). This high mortality rate isobserved at all demographic levels. Thenon-Euro-American infant death ratewas 275 per 1000 live births (Farley1970:212). The non-Euro-Americanmaternal mortality rate in 1920 was still13 per 1000 live births, while the neo- natal death ratio was 72 per 1000 livebirths (Farley 1970:209). Physicianscommonly noted that the Afro-Ameri-can stillbirth rate was two to three timeshigher than Euro-Americans ( Kiple andKing 1981:188). Farley, in an attempt toexplain both the high stillbirth rate anddecreased fertility, suggests venerealdisease, citing as evidence a 20% infec-tion rate among Afro-American femalesand a 1900 infant death rate of 2.7 per1000 live births due to congenital syph-ilis (1970:12).Donald's examination of the recordeddisease patterns shows that Afro-Amer-icans suffered a higher mortality ratethan Euro-Americans from all diseasesexcept cancer (1952:162). Using the1900 census, Farley (1970:70) lists themost frequent causes of Afro-Americandeaths as tuberculosis, pneumonia, ner-vous disorders, diarrhea, typhoid fever,and malaria. Both tuberculosis andpneumonia were major killers of Afro-Americans (Kiple and King 1981: 188)with Afro-American tuberculosis ratesbeing reported as three times higher thanEuro-Americans (Holmes 1937:76).The data and interpretations pre- sented above are derived primarilyfrom the national census and pertain tothe areas of registration. They may ormay not describe the situation in south-west Arkansas nor, in particular, thecommunity of Cedar Grove. Keeping inmind this limitation of the data, they arecompared and contrasted with thosecollected from the Cedar Grove skeletalsample.Using the cross-sectional skeletal de-mographics as a true birth cohort allowsthecalculationof mortality rates. Usingthe ratio of skeletons aged to less thanone year to total skeletons produces aninfant mortality rate of 27.5%, which isidentical to the national non-Euro-American infant mortality of 27.5%cited by Farley ( 1 970:2 1 2) for this sametime period. Using the ratio of skel-etons aged younger than birth to totalskeletons produces an estimated still-birth rate of 6.2%, which is close toFarley's (1970:209) 1920 national non-Euro-American rate of 7.2%. Althoughlife expectancy at birth obtained fromthe skeletal life table (14 years) is farbelow the 33 years for males and 35years for females reported by Farley(1970:61), the average adult skeletalages at death (males 41.2, females37.7) are reasonably close to these national statistics. The entire CedarGrove paleodemographic profile calcu-lated from the skeletal data is in excel-lent concordance with the national sta-tistics and the historic reconstructions.These results suggest not only that pal-eodemography can be used reliably, butalso that the Cedar Grove communityfollowed the national trends of in-creased mortality and decreased fertil-ity. In other words, the Cedar Grovecommunity was highly stressed duringthe post-Reconstruction period.There is abundant evidence of di-etary deficiencies in the Cedar Grove skeletal sample. The high rate of activecribra orbitalia among children (58%)and the rates of healed cribra orbitaliaand porotic hyperostosis among adults(males 33%, females 24%) indicate ex-tensive anemia. Most of the anemia can Zagreb Paleopathology Symp. 1988 Skeletal lesions from a historic Afro-American cemetery ? 125 be attributed to iron deficiency result-ing from a reliance upon com and a lackof red meat in the diet, as suggested bythe historical literature (Kiple and Ki-ple 1977:285). Some of these lesionscan be attributed to sickle cell, but thisgenetic trait should account for only asmall percentage of the observed cases(Ortner and Putschar 1981:254-258).The 24% craniotabes for children dyingbetween 3 and 20 months can be at-tributed to vitamin D deficient rickets,associated with the historically postu-lated low milk consumption caused bya high rate of lactose intolerance com-mon among Afro-Americans, and thedocumented scarcity of cattle amongthe sharecroppers (Kiple and Kiple1977:290; Kiple and King 1981:72). Atleast some of the extensive childhoodperiosteal deposits and the ossifiedhematomas among the adults may be attributable to vitamin C deficiency(Ortner and Putschar 1981:271-272)caused by a lack of fruits and vegeta-bles in the diet. These high rates of le-sions specific for dietary deficienciesindicate a very inadequate diet in theCedar Grove community between 1 890and 1927.The high frequency of active sys-temic periostitis found among both pre-matures and neonates suggests the exis-tence of at least one dominant disease.Farley's (1970:12) suggestion of con-genital syphilis can be tested with the skeletal data. Steinbock (1976:98-99)describes early congenital syphilis asoccurring between birth and three tofour years, being associated with uni- versal bone changes which include peri- ostitis and diaphyseal osteomyelitis,and having a mortality of at least 50%.Ortner and Putschar (1981:198) statethat congenital syphilis leads to earlyfetal death, delivery of a premature ormature diseased stillborn fetus, or de-livery of a living infected newborn.They further state that syphilitic perios- titis can have begun in utero and bepresent at birth (1981:198). Steinbock(1976:100-101) states that cranial os-teitis can impact both cranial tables. The association of endocranial newbone formation and long bone peri- ostitis found in a prehistoric NativeAmerican skeletal sample has been at-tributed to one of the treponematosesby Cook and Buikstra (1979:658).All five Cedar Grove skeletons withdental ages younger than birth (seven toeight fetal months) exhibit systemicperiostitis involving virtually everybone. All but 2 of the 1 1 individualsdying at birth exhibit systemic perios- titis, while one of the exceptions hasonly endocranial periostitis. Of the 18deaths between three months and 3.5years, 48% exhibit systemic periostitis.Taken together, the high frequency ofprematures with systemic periostitis,the high neonatal mortality associatedwith active systemic periostitis, and theabsence of systemic periostitis after 3.5years all suggest congenital syphilis asthe dominant disease entity. This diag-nosis is further strengthened by thepresence of Hutchinson's maxillary in-cisors on one 10-year old. These fourmaxillary incisors match the classic de-scription of Hutchinson's defect includ-ing notching, barrel shape, and con-vergent lateral margins (Steinbock1976:107). The diagnosis as Hutchin-son's incisors was also confirmed byhistological examination (Marks 1984).If the diagnosis of widespread con-genital syphilis is correct, then thecharacteristic lesions of venereal syph-ilis should also be evident in the adultsample. The ranking by frequency of{jeriostitis among the older individualsis tibia, fibula, radius, ulna, and femur.This ranking is fairly consistent withthat reported for venereal syphilis(Steinbock 1976:112). Of particularimportance is the high frequency ofperiostitis of the arm bones at CedarGrove, which is a fairly uncommon lo-cation for other infectious diseases andconsistent with the presence of venerealsyphilis (Steinbock 1976:112). Absentfrom Cedar Grove are the characteristiccranial lesions of syphilis, the sabershins, and the extensive osteomyelitisof the tibiae (Ortner and Putschar 1981:201-218; Steinbock 1976:108-136). Despite the absence of un-disputed acquired syphilis among theadults, the diagnosis of congenitalsyphilis as the major cause of still-births, high neonatal mortality, andwidespread systemic infection appearsvery reasonable.A second pathological phenomenonis indicated by the fact that, while thefrequency of lesions in all other bonescontinues to decline, the tibia, fibula,and endocranium show a relativelylarge increase between one and fiveyears (Tables 1 and 2). In fact, 58% ofthe deaths between one and five yearsoccur at 18 months of age. The 18-month modal age at death, a commonage of weaning, combined with an in-crease in infections of the tibia andfibula is highly suggestive of weanlingdiarrhea (Scrimshaw et al. 1968:216-260). This syndrome is characterizedby low-protein weaning diets whichcontribute to lowered resistance to in-fection and initiate a cycle of diarrheaand infectious disease. The presence ofprotein malnutrition resulting fromamino acid deficiencies associated withcorn- and pork-dominated diets hasbeen noted in the historic literature (Ki-ple and Kiple 1977:287).The presence of rib periostitis that isnot associated with systemic infectionhas been previously identified in twochildren ( 1 3 and 20 months), one adultmale, and two adult females. The loca-tion of these lesions on the medial sur-face of the rib body and their gross ap-pearance conform with the lesionsidentified by Kelley and Micozzi(1984) as being associated with pulmo-nary tuberculosis among cadaver speci-mens from the same time period asCedar Grove. As tuberculosis is identi-fied as the leading cause of deathamong Afro-Americans at the turn ofthe century (Farley 1970:70; Holmes1937:76), assigning 6% of the CedarGrove deaths to this disease is appropri- ate. This is not to say that the rib lesionsassociated with other infected bones arenot also attributable to tuberculosis, but Za/treh Palenpalhology Symp. J9SS 126 ? Jerome C. Rose and Philip Hartnady the 6% is a conservative estimate of thefrequency of tuberculosis.The final lesion complex to be dis-cussed is the age-cumulative increasein healed infections of the lower leg.The location of the tibia just below theskin makes it vulnerable to frequent in-troductions of bacteria from relativelyinconsequential accidental wounds(Ortnerand Putschar 1981:132). Thus,the frequency of tibia infections shouldincrease under conditions of reducedresistance to disease where the reduc-tion of the body's defense mechanismspermits the infectious agents to becomeestablished. Periostitis of the tibia isfrequently found in archeologicallyderived skeletal collections (Ortnerand Putschar 1981:131; Steinbock1976:82). in contrast, we have foundperiostitis of the fibula to be propor-tionally less frequent in prehistoricAmerican skeletal samples (i.e., 50%or less than the tibia rate) and interpretthe infections of the fibula as being as-sociated with either major leg trauma orspread of infection from the tibia.Thus, increases in fibula infections canbe used to indicate a reduction in dis-ease resistance. The age-specific fre-quencies of adult healed tibia infectionsrange between 56 and 90%, while thefibula rates range between 33 and 100%(Table 3). The virtual absence of activelower leg infections indicates that theselesions were not associated with thecause of death, but represent previousepisodes from which the individuals re-covered. Both the high frequency oftibia and fibula periostitis and the con-cordance of rates between the twobones suggest diminished disease re-sistance among the people of CedarGrove. This interpretation is consistentwith the historical literature which sug-gests poor diet and high stress for Afro-Americans in the post-ReconstructionSouth. Conclusions In this analysis of the Cedar Grove in-fection data we have attempted toachieve two goals: first, to improve ourunderstanding of Afro-American dis-ease patterns in the post-Reconstruc-tion period of southwest Arkansas, andsecond, to demonstrate that paleo-demographic and paleopathologicalanalysis can provide interpretationscompatible with historic interpreta-tions. The Cedar Grove skeletal de-mography is in excellent concordancewith the census data. There was highinfant mortality (27.5%), high frequen-cy of stillbirths (6.2%), and high adultmortality with average ages of death at41 years for males and 38 years forfemales. Skeletal evidence for dietarydeficiencies including iron, vitamins Dand C, and protein are in agreementwith the historical reconstructions.The distribution of proliferative le-sions by affected bones of the skeletonand age indicates the presence of fourmajor disease clusters. The systemicinfections among the neonates indicatethe presence of widespread congenital syphilis. Although the classic stigmataof venereal syphilis are not foundamong the adults, the presence of le-sions on the bones of the arm is sugges-tive. The peak mortality at 18 monthsand an associated increase in prolifera-tive lesions indicate the presence of theweanling diarrhea syndrome and, byimplication, protein deficiency. A dra-matic age-cumulative increase inhealed lesions of the tibia and fibulaindicates continued adult malnutritionand high overall stress loads. The fre-quent rib infections are consistent witha high frequency of pulmonary tuber-culosis. All of these conclusions arecompatible with the interpretations pro-duced by historical analysis of the doc-umentary data. Acknowledgments Financial support for the Cedar GroveCemetery excavation and analysis wasprovided by the U.S. Army Corps ofEngineers, New Orleans District, to theArkansas Archeological Survey and thesenior author. Literature cited Bocquet-Appel. J-P..andC. Massel. 1982.Farewell to Paleodemography. Journal ofHuman Evolution. 11:321-333.Buikstra, J.E.. and D.C. Cook. 1980. Pal-eopathology: An American Account. An-nual Reviews of Anthropology, 9:433-470.Buikstra, J. E., and L.W. Konigsberg. 1985.Paleodemography: Critiques and Con-troversies. American Antl\ropolo)>ist. 87:316-333.Christenson, D.E. 1958. The Negro'sChanging Place in Southern Agriculture.In The Research Council of the FloridaState University. The Nef^ro in AmericanSociety. 41-52. Tallahassee: FloridaState University.Cook, D.C, and J.E. Buikstra. 1979.Health and Differential Survival in Pre-historic Populations: Prenatal Dental De-fects. American Journal of Physical An-thropology. 51:649-664.Donald, H.H. 1952. The Negro Freedman:Conditions of the American Negro in theEarly Years after Emancipation. NewYork: Henry Schuman.Farley, R. 1970. Growth of the Black Popu-lation: A Study of Demographic Trends.Chicago: Markhani Publishing.Gibbs, T. . K. Cargill, L.S. Lieberman. andE. Reitz. 1980. Nutrition in a Slave Pop- ulation: An Anthropological Examina-tion. Medical Anthropology. 4:173-262.Gilbert. B.M., and T.W. McKern. 1973. AMethod for Aging the Female Os Pubis.American Journal ofPhysical Anthropol-ogy. ?,S3\-i8.Graves. J.W. 1967. The Arkansas Negroand Segregation 1890-1903. M.A. the- sis. University of Arkansas. Fayetteville. Zagreb Paleopathology Symp. 1988 Skeletal lesions from a historic Afro-American cemetery ? 127 Holmes, S.J. 1937. The NenroS Strugglefor Survival: A Study in Human Ecology.Berkeley: University of California Press.Kellcy, M.A.. and M.S. Micozzi. 1984.Rib Lesions in Chronic Pulmonary Tuber- culosis. American Journal of PhysicalAnthropology. 65:381-386.Kiplc, K.F., and V.H. King. \9^\. AnotherDimension to the Black Dia.spora: Diet.Disease and Racism. Cambridge. U.K.:Cambridge University Press.Kiple, K.F.. and V.H. Kiple. 1977. SlaveChild Mortality: Some Nutritional An-swers to a Perennial Puzzle. Journal ofSocial History. 10:284-309. Krogman,W.M., and M.Y. Iscan. 1986. The Hu-man Skeleton in Forensic Medicine.Springfield, 111.: Charles C Thomas.Lovejoy, CO., R.S. Meindl, T.R.Pryzbeck, and R.P. Mensforth. 1985.Chronological Metamorphosis of the Au- ricular Surface of the Ilium: A NewMethod for the Determination of AdultSkeletal Age at Death. American Journalof Physical Anthropology. 68: 1 5-28.Marks, M.K. 1984. Congenital Trep-onematosis in an Early Twentieth Cen-tury Rural Black American Cemetery.American Journal ofPhysical Anthropol-ogy. (>\.\90.McKcm, R.W., and T.D. Stewart. 1957.Skeletal Age Changes in Young Ameri-can Males. Analyzed from the Standpointof Identification. Technical Report Ep-45. Natick, Mass.: Headquarters, Quar-termaster Research and DevelopmentCommand.Ortner, D.J., and W.G.J. Putschar 1981.Identification of Pathological Conditionsin Human Skeletal Remains. Smith.so-nian Contributions to Anthropology 28.Washington, D.C.: Smithsonian Institu-tion Press.Powell, M.L. 1985. Health, Disease, and Social Organization in the MississippianCommunity at Moundville. Ph.D. disser-tation. Northwestern University, tivan- ston. III.Schour, I., and M. Masslcr. 1941. The De-velopment of the Human Dentition. Jour-nal of the American Dental Association.28:1153-1160.Scrimshaw, N.S., C.E. Taylor, and J.E.Gordon. 1968. Interactions ofNutritionsand Infection. Geneva: World Health Or-ganization.Slampp, K.M. 1965. The Era of Recon-struction 1865-1877. New York: AlfredA. Knopf.Steinbock. R.T. 1976. PaleopathologicalDiagnosis and Interpretation: Bone Dis-eases in Ancient Human Populations.Springfield. III.: Charles C Thomas.Swedlund. A.C., and G.J. Armelagos.1976. Demographic Anthropology. Du-buque. Iowa: William C. Brown.Sylva. M.F. 1981. Black Populations inArkansas. M.A. thesis. University ofArkansas, Fayetteville.Ubelaker, D.H. 1982. The Development ofAmerican Paleopathology. In F. Spencer, ed., A History ofAmerican Physical An-thropology 1930-1980. 337-356. NewYork: Academic Press.Van Gerven, DP., and G.J. Armelagos.1983. Farewell to Paleodemography?Rumors of its Death Have Been GreatlyExaggerated. Journal of Human Evolu-tion. 12:353-360.Watkins, B. 1985. Historical Background.In J.C. Rose, ed. , Gone to a Better Land:A Biohistory of a Rural Black Cemeteryin the Post-Reconstruction South, 6-17.Fayetteville: Arkansas ArcheologicalSurvey.Weiss, K.M. 1973. Demographic Modelsfor Anthropology. Society for AmericanArchaeology Memoirs. 27. Summary of audience discussion: Thefrequency of infections in this reportedgroup is four to five times higher than thatfound in the preceding slave period. Histor-ical literature from the 1890-1930 periodindicates biologists found Afro-Americansin such a severe state of demographic dis-equilibrium that they predicted their extinc-tion in America by 1950. It may have beentheir participation in the public assistanceprograms of the 1 930s that reversed the sit- uation.The endoeranial periostitic lesions are in-triguing since, if they were infectious, it isnot easy to postulate how fatal meningitiswas avoided for a period long enough topermit the observed osseous response. Onepossibility may be that the lesion was a re-flection not of acute, pyogenic disease but rather of intrauterine treponematosis. Thisconsideration is based on the slender evi-dence of observing that all cases were inneonates or feti and that Hutchinson's teethevolve in a milieu of spirochete-infectedtissue.While it might be intriguing to view thisas a population healthy enough to resist ma-jor infections, their calculated infant mor-tality and stillbirth rates are identical withthe disastrous contemporary demographic statistics, indicating that this populationwas not healthier than others, but insteadwas in a devastatingly unhealthy state. Zagrrb Pateopaihology Symp. t988 Paleopathological study oninfectious diseases in Japan Takao Suzuki 1 oday's clinical features of infection including its inci-dence, symptoms, course, and pathological morphology inliving tissues have been dramatically changed by the wide-spread use of antibiotics after World War II. Inflammatorychanges commonly found in archeological skeletal remainsprovide good evidence of the vivid reaction of extrinsic in- sults to the bone. However, it is not necessarily easy to diag-nose the precise, causative disease producing such inflam-matory changes based on the morphological features. On thispoint, Putschar ( 1966:59-60) stated as follows: Inflammatory bone lesions pose much more serious diag- nostic problems and therefore deserve more detailed discus- sion. Periosteal deposition of bonewith or withoutthickening and architectural change of the underlying cor-tex of the diaphysis of long bones is probably the mostcommon inflammatory lesion found in prehistoric material.The lesion often appears to be in a chronic or healed stage,and it is frequently impossible to ascertain whether thechanges arc traumatic or infectious in origin. In the present study, inflammatory lesions appearing in ar-cheological skeletal materials have been examined mac-roscopically and categorized in order to use them as an in-dicator of the health status in earlier populations. Theprocedure of this study deals with the classification of theinflammatory lesion in terms of gross morphology, and itslimitations and availability in reconstructing a pattern ofhealth. Even the equivocal lesions existing between non-specific and specific disease, which may be an unavoidableproblem in paleopathology, have been considered as a part ofthe available information for epidemiological analysis.In this context secular changes regarding the frequency ofinfectious diseases in the skeletal populations in Japan havebeen examined and interpreted with respect to bioculturalbackground. Among specific diseases, tuberculosis andsyphilis have been extensively studied. These two diseasesare viewed from the standpoints of origin, dissemination andprevalence in the Japanese archipelago. 128 Geographic, tiistoric, and archeologicalbackground The Japanese archipelago is made up of four main islands(Honshu, Shikoku, Kyushu, and Hokkaido) which togetherwith more than 4000 smaller islands lie off the east coast ofAsia showing a crescent shape. The climate of these islands,ranging from subfrigid to subtropic, is mostly a temperateand oceanic type with four distinct seasons. More than 60%of the land is mountainous, and most of this is covered withforests. All of these environmental factors may have a con-nection with the diseases of the inhabitants as well as theecological, biological, and sociological factors.The origin of the Japanese people is not altogether clearwith respect to location and time. However, paleolithic stoneimplements suggest that their ancestors inhabited these is-lands for more than ten thousand years. The beginning of theJapanese neolithic period, Jomon, is still controversial andunproven to many anthropologists. However, this prehistoricperiod lasted at least several thousand years, and ended atabout the third century B.C. The main subsistence strategiesduring the Jomon period were hunting, fishing and gathering.The Jomon people made a lot of clay utensils including pot-tery characterized by cord-marking (Jomon). The Jomonpeople were buried under shell mounds which have protectedtheir skeletal remains from volcanic and acid soil.During the Eneolithic period, Yayoi (third century B.C. toabout third century a.d.), which followed the Jomon period,a large number of immigrants migrated to the western part ofJapan via the Korean Peninsula. Immigrants mixed with theJomon people who were aboriginals in this area. It was dur-ing this period that the Japanese mastered the art of ricecultivation, began to use metal implements, and set the fun-damental pattern of Japanese tradition and life. From thepaleopathological point of view, some new infectious dis-eases seem to have been transmitted from the Asian continentto Japan with such a huge numberof immigrants at that time.According to the traditional history of Japan, the migration Zagreb Paleopathology Symp- 1988 I Paleopathological study on infectious diseases in Japan ? 129 from the Korean Peninsula continued until around the eighthcentury a.d. Japanese living in western areas were likely tobe atTected by such migrants physically, although the Ainu inHokicaido seemed to remain unmixed (Hanihara 1985).Therefore, the influence of the admixture which took place after the Yayoi period is still evident in western Japan. How-ever, the eastern Japanese maintain some characteristicswhich are similar to the Ainu to a greater or lesser extent(ibid.).After consolidation of Japan into a single nation in thefourth century, successive emperors strengthened the foun-dation of the country by introducing various aspects of conti-nental learning and culture. These included the Chinesewriting system, ideology (Confucianism) and religion (Bud-dhism). In particular. Buddhism recommended cremation,and after the protohistoric period people did not make shellmounds as a burial site, so that complete skeletal remainsbelonging to the protohistoric period are ditficult to findexcept for some special burial ca.ses. Materials The skeletal materials used in this study were from collec-tions of various periods and sites housed in several univer- sities. Only adult skeletons were examined for their patho-logical changes because of the abundance in quantity andquality. Four major skeletal series can be considered as thecore of this study: 1 . The Jomon skeletal series consisted of 272 individualskeletons from eight sites (seven from shell mounds and onefrom a cave site). Among them, six skeletal series (Hobi. Ko,Nakazawahama, Ubayama, Kasori, Yosekura) are housed inthe Department of Physical Anthropology of the UniversityMuseum. The University of Tokyo, and they are registeredand catalogued by Endo and Endo ( 1979). Two other Jomon skeletal series from Tsukumo and Yoshigo are housed in theDepartment of Physical Anthropology, Kyoto University.2. The Edo skeletal series consisted of 308 femora and 253tibiae housed in the Department of Physical Anthropology ofthe University Museum, The University of Tokyo. Whole,individual skeletons of the Edo period (latest medieval, ear-liest modem) could scarcely be excavated because most buri- al sites of this period, particularly in Edo (old Tokyo) city,were secondary and reburied sites. Therefore, the skeletalmaterials which were from five Edo sites (Unko-in,Joshin-ji,Fudo-ji, Hoden-ji and Edogawa-bashi) could not be identi-fied as to age, sex, or individual. Besides the long bonematerial of femora and tibiae, 923 skulls of the Edo periodwhich have already been studied by the author with respect tocranial syphilis (Suzuki 1984a) were used for this study.3. The Ainu skeletal series consisted of 178 individualskeletons, and were from two northern islands: Hokkaidoand Sakhalin. These skeletal materials, believed to be fromthe latest medieval and earliest modem Ainu, correspond to the Edo period and were collected by Koganei in Hokkaido(Koganei 1894) and by Kiyono in Sakhalin (Kiyono1943,1949). The materials from the Hokkaido Ainu, called "Koganei collection," are housed in the Department of Anat-omy of the University Museum, The University of Tokyo.The materials of Sakhalin Ainu, a part of the "Kiyono collec-tion," are housed in the Department of Physical Anthropol-ogy, Kyoto University. The detailed paleopathological stud-ies on these major Ainu skeletal series have already beenconducted and reported by the author (Suzuki and Ikeda1981; Suzuki 1984b, 1985b).4. The Meiji Japanese (early modem) skeletal series con-sisted of 113 whole, individual skeletal materials from theKanto area (central part of Honshu). These materials are nowhoused in the Department of Anatomy, Sapporo MedicalCollege. Their demography (sex, age and birthplace) is wellrecorded. These individuals ranged from 20 to 80 years old.They died between 1927 and 1944. Some osteological andphysical anthropological studies on this series have been car-ried out by several authors (Mitsuhashi 1958; Wada 1975;Hashizaki and Kaneko 1979; Higuchi 1983).The locations of the major sites of these four skeletal seriesare indicated in Figure 1 and detailed contents of individualsand skeletal parts of these series are listed in Table 1 . Furthemiore. in addition to these four major skeletal seriesa few cases exhibiting interesting pathological conditionswere used in the study. These special cases will be describedas to the sources and data in each case. MethodsGROSS OBSERVATION Pathological changes appearing on the skeleton from Jomonto modem Japanese skeletal series were examined by grossobservation and, in most cases, by x-ray film. Neither ahistological nor a microscopic study has been carried out.The examination was carried out only on adult skeletalremains, because the subadult skeletons were few and mostof them were so badly damaged that the identification andpathology were difficult to ascertain. The skeletal parts ob-served in this study included skull, sternum, and vertebralcolumn, and also limb girdle bones such as the scapula,clavicle, and pelvis, as well as long bones of the extremitiesincluding humerus, radius, ulna, femur, tibia, and fibula.Small bones of the hand and feet were excluded as well asfragmented ribs. From the Edo period only skull, femur, andtibia were examined because of the commingled state causedby reburials.Lesions appearing in both the maxilla and mandiblecaused by periodontal diseases were excluded in this study.Those inflammatory changes, though frequently appearingin archeological specimens with abscess formation, shouldbe classified into another category, such as "lesions of jawsand teeth" (Ortner and Putschar 1981:436-456). Zagreb Paleopathology Symp. 1988 130 ? Takao Suzuki SAKHALIN CHINA JAPAN Figure 1. Major archeological sites from which skeletalremains were used in this study. Jomon sites (small black circles): a. Nakazawahama; i>, Ubayama;r, Kasori;^/. Hobi; e. Yoshigo;/, Ko; g. Tsugumo; h, Yosekura. Yayio, Kofun.and Medieval sites (large black circles): a, Katsuyama-Tate;b. Unoki-Kofun; c. Shiroyama-Kofun; d, Zaimokuza; e. Ichino-Torii. Edo (old Tokyo) sites: open squares. Earlymodem Japanese sites: open triangles. Ainu sites: open cir- cles. TAXONOMY OF INFLAMMATORY CHANGE IN THE BONE The periosteum, cortex, and medulla of bone have such aclose relationship that infectious change occurring in one partof the bone cannot help but influence another part. In dry-bone specimens, almost all infections usually can beclassified as either osteomyelitis or periostitis. Periostitis isdefined as periosteal reactive bone changes with irregular,fine-porous and spongy deposition located only exterior tothe cortex with no involvement of the underlying cortex. Themost common feature of such periosteal reaction tends to be "plaquelike" periostitis (Figure 2) which may show variousdegrees of severity or stages, as stated by Stothers andMetress (1975). Osteomyelitis is defined as infiammatorychanges spread through the medullary cavity and, in manycases, the cortical bone. The most common feature of sup-purative osteomyelitis is characterized by sequestrum, invol-ucrum, and cloacal formation, particularly in the long bones(Figure 3). As is well known, there is an uncommon form ofchronic osteomyelitis characterized by remarkable scleros-ing of the lesion without any cloacal openings, which canusually be seen in the shafts of the lower extremities of adults(Figure 4), the so called "sclerosing osteomyelitis of Garre."From the viewpoint of modem clinicopathology, inflam-matory changes in living tissue are usually classified into twocategories: nonspecific inflammation and specific inflamma-tion. This classification is also available in the paleopatho-logical field and actually has been used by some authors(e.g., Putschar 1966:60; Stothers and Metress 1975; Stein-bock 1976:60,86; Ortner and Putschar 1981:104,129-138;Goodman et al. 1984). In this study, therefore, inflammatorybone changes are also categorized into two groups, non-specific and specific bone inflammation. In the dry-bonespecimen, nonspecific inflammation can be defined as an Table l. Skeletal material studied Paleopathological study on infectious diseases in Japan ? 131 Figure 2. Schematic representation ofmoderate "plaquelike" periostitis and acase from Jomon site (Tsukumo siiell-mound). Figure 3. Schematic representation of ad-vanced chronic osteomyelitis with seques-trum, involucrum, and cloaca formation(MacCallum 1920). Zaf;reb Paleopathology Symp. 1988 Figure 4. Sclerosing osteomyelitis of Garre from modem Japanese skeletal mate- rial: a. pathological (right) and nonnal (left) bone specimen; b. x-ray film. ordinary inflammatory reaction represented mainly by peri- ostitis with plaquelike bone deposition and, in the advancedcase, by osteomyelitis. On the other hand, specific inflam-mation can be characterized by a peculiar granulomatouslesion even in the dry bones which may be detectable in grossexamination. Actually, in the typical/advanced cases of tu-berculosis and syphilis, their inflammatory changes can bediagnosed by characteristic morphology and peculiar dis-tribution of the lesion in the skeleton. In some cases, ofcourse, geographical and epidemiological informationshould be considered in order to evaluate the bone lesion anddifferentiate between possible diseases which affect the skel-eton in a similar fashion (Buikstra 1976).However, in the case showing slight inflammatory bonechange or even in the advanced changes with ordinal perios-teal reaction, it is not always possible to difterentiate thesetwo categories with certainty. Only typical and demonstrablecases showing peculiar morphology caused by specific infec-tion can be diagnosed in the dry-bone specimens. In otherwords, it is quite natural that overlapping between non-specific and specific inflammatory change, particularly inthe early stage of bone infection, would occur in archeologi-cal specimens. Therefore, the etiology of periostitis, which isvery common in archeological specimens, cannot always beidentified. This is one of the reasons why periostitis has oftenbeen treated as an independent entity in paleopathology. Onthis problem, Ortner and Putschar (1 98 i : 1 3 1) stated the fol-lowing: 132 ? Takao Suzuki / \ Nonspecific Inflammation \PeriosiiilsexsudativePeriostitispurulentaPeriostitisfibrosa / Osteomyelitis suppurativesequestruminvolucrumcloaca lormation Specific Inflammation / Periostitistuberculosa\ Periostitis ossificans "plaquelike" depositiontfiickening of exteriorsmaller/larger poresuneven hypervascularity \Spondylitis tuberc(kyphosis, etc )Dactylitis tuberc(spina ventosa) Osteomyelitis k-Independent entityinpaleopathology Periostitissyphiliticay / \Caries sicca in the skull(stellate scars, etc.)Gummatousperiost - osteomyelitis(snail track pattern, etc )y Figure 5. Lesions in specific and nonspecific inflammatory conditions of bone. The main reason for this difference between clinical andpaleopathology is that many of the periosteal reactions maybe part of the expression of a specific disease process,which can be identified in a living patient, whereas in ar-cheological specimens the pathological characteristics nec-essary to make a specific diagnosis are not available. Thiswould have the effect of increasing the frequency of non- specific periostitis in archeological skeletal series. Such a special situation of peiiostitis in paleopathology isshown in Figure 5. Thus in the present study, due to thepossible admixture of these two kinds of infections amongthe archeological specimens, the author cannot help but dealwith all inflammatory changes in the bone as nonspecificinflammation, excluding only the typical/demonstrable caseshowing specific changes of bone tuberculosis and syphilis. Results Gross examination of the infectious changes was conductedon four skeletal series: the Jomon (prehistoric) series includ-ing 272 individuals, the Ainu series of 178 individuals, theMeiji (early modem; antibiotic era) Japanese series of 1 13individuals, and the Hdo (latest medieval/earliest modem)Japanese series consisting of 923 skulls, 308 femora, and 253tibiae. The data on cranial syphilis of the Edo series wasquoted from the previous study carried out by the author(Suzuki 1984a). FREQUENCY OF THE INFECTIOUS LESION. The TCSUltS areshown in Table 2. The highest frequency can be seen in theMeiji Japanese series and the lowest was in the Jomon series. SEX DIFFERENCES OF THE FREQUENCY. ExCCpt for the EdoJapanese series, the number and total frequency of infectiouslesions in both sexes are shown in Table 3. There is no statis-tical significance between the male and female frequencies(X^ = 0.267 < p(O.Ol)]. The frequency of cranial syphilis inthe Edo series also fails to reveal statistical significance be-tween both sexes [x^ = 2.04 < p (0.01)]. SEVERITY OF INFECTIOUS CHANGE. Most infcCtioUS ICSionSof bone can be generally classified as either periostitis orosteomyelitis. As is well known, periostitis shows variousdegrees of involvement, from slight and weak change tosevere and drastic (Stothers and Metress 1975; Lallo et al.1978). In this study the severity of such infectious changewas basically classified into periostitis and osteomyelitis,and f)eriostitis was subdivided into two categories, slight andsevere. Slight periostitis was defined as the extent of involve-ment of the periosteal surface (Lallo etal. 1978) correspond-ing to the stage 1-11 proposed by Stothers and Metress(1975). Severe periostitis was defined by the nature of tissuedestruction?whether pitted, ridged, scarred, or showingsinus tracts (Lallo etal. 1978). The result is shown in Table 4. It should be noted that there is no clear evidence of os-teomyelitis in the Jomon series. Zagreb Paleopathology Symp. 1988 II Table 2. Frequency of infectious lesion types Period Category of No. (%) Total/no. (%)(no.) infection individuals Paleopathological study on infectious diseases in Japan ? 133 Table 3. Sex differences of lesions' frequencies Period Category oflesion Male Female Total 134 ? Takao Suzuki Paleopathological study on infectious diseases in Japan ? 135 Table 6. Population number from earliest Jomon (prehistoric) to Kofun(protohistoric) period (Koyama 1984) Period Jomon Yawi Kofunearliest early middle late latest Population 20100 105500 261300 160300 75800 594900 5399800numberDensity/km^ 0.07 0.36 0.89 0.55 0.26 2.02 18.37 Table 7. Reported palaeopathological cases of bone tuberculosis Designation Period Sex Age Location Reporter Shiroyama-No. 3 KofunUnoki-No. 3 KofunAsahidai - No. 9 Kofun Ainu -A - 1336 Ainu M Adult Spine (lumbar-sacrum) Ogata 1972F Mature -senile Spine (thoracic-lumbar) Suzuki 1978M Mature - senile Spine (thoracic-lumbar) Tashiro 1982RibsF Adult Sacrum Suzuki 1985a Koyama's (1984:10-39) estimation of the population fromthe earliest Jomon to the protohistoric period is shown inTable 6. The average population density calculated in theJomon period (0.43/km-) is about one-fifth of the Yayoiperiod (2.02) and one-fortieth of the Kofun period (18.37).Furthermore, Kobayashi (1967) stated that the average age atthe time of death for the individual over 1 5 years of age was3 1 . 1 for males and 3 1 .3 for females. It is quite probable thatthe Jomon people had rather short lives, probably caused bysome environmental factors such as unstable food supply,hard labor in hunting-gathering-fishing activities, and un- sanitary living conditions. These environmental factors alsomay have influenced the inflammatory process in the bone.The following tendencies can be suspected among the Jomonpeople; infection may extend rather easily to the bone, andindividuals involved in such an infectious process tend to diebefore periostitis becomes chronic and develops into moreadvanced osteomyelitis.On the other hand, during the historic periods, probablydue to the development of agriculture and gradual improve-ment of hygienic conditions, individual resistance againstinfectious diseases may change to produce more severelyinfected conditions of the bone as well as lengthen the aver-age span of life at the social level. However, at the same time it should be noted that other new epidemic diseases had beenintroduced and prevailed widely in this country at that time,accompanied by an increase in population density anddomiciliation. These epidemic diseases consisted of the twospecific infections, tuberculosis and syphilis. Zagreb Paleopathology Symp, 19H8 ORIGIN AND PREVALENCE OF SPECIFICDISEASES IN JAPAN It is remarkable that there have been neither typical nor sus-pected cases showing specific inflammatory bone changesamong a huge number of Jomon skeletal remains excavatedfrom various archeological sites in the Japanese archipelago.In the present study also, except for the Jomon skeletal series,typical/demonstrable cases of tuberculosis and syphilis werelimited to the Edo and Meiji Japanese skeletons as well as theAinu skeletal series.Four typical cases of spinal tuberculosis have been re-ported to date in Japan (Ogata 1972; Suzuki 1978; Tashiro1982; Suzuki 1985a) as shown in Table 7. None of thembelonged to the prehistoric ( Jomon) population from which agreat deal of well-preserved skeletons have been studied.The three oldest cases (Figure 7) belong to the protohistoric(Kofun) population in which there are considerably fewerskeletons than in the Jomon population. There seem to be twoalternative possibilities why no case of bone tuberculosis hasbeen found among so many Jomon skeletal remains. The firsthypothesis attributes it to the lower population density of theJomon period. Tuberculosis is a density-dependent diseaseand may have become established in human populations asthe result of the appearance of such population aggregates(Cook 1984). In this sense tuberculosis might have existed ina very limited area as a local endemic form. Tuberculosisreached epidemic proportions after the Yayoi or Kofun period 136 ? Takao Suzuki Figure 7. Two cases of tuberculosis in the Kofun period: left, spine of adult malefrom Shiroyama-Kofun site (courtesy of Dr. T. Ogata); n^/i/, spine of maturefemale from Unoki-Kofun site. following a rapid increase of population density. Neverthe-less, it is still strange that not a single case of bone tuber-culosis has been found from the Jomon skeletal remains. AsMorse ( 1961 ) pointed out, if prehistoric tuberculosis did ex-ist there should be many cases of typical spinal tuberculosisfound among the large amount of excavated skeletal mate- rial. The second hypothesis is more probable, dealing withthe migration of the causative organism Mycobacterium tu-berculosis. A great number of immigrants from the Asiancontinent migrated to this island country via the Korean Pen-insula during the Kofun period (protohistoric, ca. third toseventh century a.d.). Not only did they introduce variouscultural characteristics including the Chinese writing system,agricultural methods, and crafts, but they brought some newinfectious diseases, probably including smallpox and tuber-culosis, which disseminated throughout the country accom-panying a rapid increase of population. The oldest writtenrecord of respiratory tuberculosis appeared in a Buddhistmedical book published in the 12th century in Japan. Manymedical documents, particularly in the Edo period, describeda high prevalence of lethal, respiratory tuberculosis amongthe p)eople.Unlike tuberculosis, the origin, dissemination and preva-lence of venereal syphilis have already been elucidated by theold medical documents. According to medical historians (e.g., Fujikawa 1904:172-177, 1912:42; Dohi 1921:70-75),the first outbreak of a virulent venereal infection appeared inthis country in the decade following 1510, the lateMuromachi period, and suddenly prevailed in epidemic pro-portions. The oldest documents describing the appearance ofsyphilis in Japan are two documents written in a.d. 1512 and1513. They showed that the first large outbreak of syphiliswas in the western part of Japan and then spread to the north-eastern part within a year or so. The people at that time calledthis curious epidemic disease Tau-mo (Chinese eruption) orRyukyu-mo (Ryukan eruption), which represent the originalepidemic area before they were involved. This virulent epi-demic of syphilis struck the unsuspecting Japanese withoutdistinction as to age and sex. During the Edo period, thepeople were very familiar with syphilis and called it by vari-ous names. Many documents deal with the clinical man-ifestations and therapies for syphilis during the mid and latterEdo period.Koganei ( 1 894) described a case of an Ainu archeologicalskeleton showing typical changes of osseous cranial syphilis(Figure 8), and Suzuki ( 1 963: 1 3- 1 5) reported the oldest caseof osseous cranial syphilis from the Muromachi period (Fig-ure 9), stating that 3 out of 23 skulls ( 13.0%) had the typicalfeatures of os.seous syphilis. Another old case showing syph-ilitic change in the skeleton from a ruin of a medieval castle in Zagreb Pateopathology Symp. 1988 . Paleopathological study on infectious diseases in Japan ? 137 Figure 8. Typical demonstrable case of cra- nial syphilis from an Ainu skeletal remains(originally reported by Y. Koganei in 1894). Figure 9. Typical demonstrable case of cra-nial syphilis from the Muromachi (medieval)skeletal remains (originally reported by H.Suzuki in 1963). Figure 10. Two typical demonstrable cases of cranial syphilis from the Edo (latest medieval/earliest modem) skeletalremains (originally reported by the author in 1984.) Hokkaido has been reported by the author (Suzuki 1984c).Furthermore, on the subject of the epidemic of syphilis dur-ing the Edo period, 50 of 923 (5.4%) Edo skulls could bediagnosed as demonstrable cases of osseous syphilis (Figure10) and in the biocultural background of the Edo people andits society these were interpreted as proving a high preva-lence of syphilis (Suzuki 1984a).Another major specific disease that affects the skeletalsystem, particularly the facial and foot bones (M^llcr-Christensen 1964), is leprosy. Recently some archeological Zagreb Paleopathology Symp. 1988 cases from the medieval and early modem periods have beenthought to be possible cases of leprosy in this country, thoughto date they have not been published. There are also no casesof leprosy found in the Jomon skeletal series.Nonvenereal fomis of trcponematosis such as yaws (fram-besia) and pinta must be dilTerentiatcd from venereal osseoussyphilis if these two diseases coexist in the same area. InJapan, however, there has been no evidence of the existenceof such tropical, endemic, nonvenereal infections either inthe past or at the present time. 138 ? Takao Suzuki ConclusionsA paleopathological study emphasizing infectious bone dis-eases was conducted on the skeletal mateinals from Jomon(prehistoric) to Meiji (early modem) Japanese and the Ainuf)eople. The frequencies, sex differences, and severity of theinflammatory lesions in the bones are presented as well assome interesting cases from various archeological sites. Ataxonomical problem in the description of inflammatorychanges is also discussed.Among a large numberof the Jomon skeletal remains therewas no evidence of specific infectious diseases. The inflam-matory changes represented by slight/moderate plaquelikeperiostitis in the Jomon series seemed to be caused only bynonspecific infections. On the other hand, the other skeletal series included not only typical/demonstrable bone tuber-culosis and syphilis but also chronic/advanced osteomyelitisbesides ordinary plaquelike periostitis, which document thecoexistence of both nonspecific and specific infections in theEdo, Meiji, and Ainu populations. This difference foundbetween the Jomon and the other series was consistent withbiocultural differences such as the introduction of agricul-ture, settlement, increase ofpopulation density and urbaniza-tion in this country.The qualitative changes of bone infection by the two spe- cific infectious diseases of tuberculosis and syphilis werealso considered from the standpoint of their origin (transi-tion), dissemination and prevalence in this country. Acknowledgments The author is deeply indebted to Professor Akio Yamauchi ofthe Department of Anatomy (III), Faculty of Medicine, TheUniversity of Tokyo, Professor Kazuro Hanihara and Associ-ate Professor Banri Endo of the Department of Anthropol-ogy, Faculty of Science, The University of Tokyo, and Pro-fessor Jiro Ikeda of the Department of Anthropology, KyotoUniversity, for their kind permission to examine the valuablematerials in their universities.The author is also very grateful to Professor YoshiatsuNaito of the Department of Anatomy (II), Faculty of Medi-cine, Nagasaki University, and Professor Takahiko Ogata ofthe Department of Oral Anatomy (II), Kagoshima UniversityDental School, for allowing him to use their valuable illustra-tions of infectious diseases in the bones.The author also wishes to express his gratitude to Donald J.Ortner, Curator of the Department of Anthropology, Smith-sonian Institution, for his kindness in reading the manuscriptand offering many helpful suggestions. Literature cited Brothwell, D. 1961. The Paleopathology of Early British Man; AnEssay on the Problems of Diagnosis and Analysis. Journal of theRoyal Anthropological Institute. 91:31 8-344.Buikstra. J.E. 1976. Differential Diagnosis: An EpidemiologicalModel. Yearbook of Physical Anthropology. 20:316-328.Cook, D.C. 1984. Subsistence and Health in the Lower IllinoisValley: Osteological Evidence. In M.N. Cohen and G.J. Ar-melagos, eds. , Paleopathology at the Origin ofAgriculture. 235-270. New York: Academic Press.Dohi. K. 1921. The World History of Syphilis. Tokyo: Keiseisha.Endo, Y., and B. Endo. 1979. Catalogue ofSkeletal RemainsfromNeolithic Jomon Period in Japan Presen'ed in the University' ofTokyo. Material Report 3. Tokyo: University Museum, Univer- sity of Tokyo.Fujikawa, Y. 1904. The History ofMedicine in Japan. Tokyo: Kei-seisha. 1912. The History of Di.teases in Japan. Tokyo: Nip-ponsha.Goldstein, M.S. 1957. Skeletal Pathology of Early Indians inTexas. American Journal ofPhysical Anthropology. 15:299-307.Goodman, A.H.. J. Lallo. G.J. Armelagos. and J.C. Rose. 1984.Health Changes at Dickson Mounds, Illinois (AD. 950-1300).In M.N. Cohen and G.J. Armelagos. eds. . Paleopathology at theOrigins of Agricidture, 271-305. New York: Academic Press.Hanihara. K. 1985. Origins and Affinities of Japanese as Viewedfrom Cranial Measurements. In R. Kirk and E. Szathmary. eds.,Out of Asia. 105- 112. Canberra: Journal of Pacific History.Hashizaki, T. and M. Kaneko. 1979. Study of the Spinal CanalStenosis with Special Reference to Its Bone Factors. SapporoMedical Journal. 48:143-156.Higuchi, Y. 1983. A Study on the Morphological Changes in theHuman Cervical Apophysial Joints with Increasing Age on Mac-erated Skeletons. Sapporo Medical Journal. 52:181-204.Kiyono. K. 1943. A Study on the First Man in Japan. Tokyo:Hagiwara-Seibunkan . 1949. The Racial Problems Based on the OsteologicalStudies of the Human Skeletal Remains in Japan. Tokyo:Iwanami-Shoten.Kobayashi, K. 1967. Trend in the Length of Life Based on HumanSkeletons from Prehistoric to Modem Times in Japan. Journal ofthe Faculty ofScience. 3:109-160. University of Tokyo, Section5, Anthropology.Koganei. Y 1894. Beitrage zur Physischen Anthropologic derAinu. I. Untersuchungen am Skelete. Mitteilungen Medi-cinischen Fakultat Kaiserlich. 2:1-250. Japan Universitat.Koyama, S. 1984. Jomon Period. Chuko-Shinsho. 733. Tokyo:Chuko-Koronsha.Lallo, J., G.J. Armelagos. and J.C. Rose. 1978. Paleoepidemiolo-gy of Infectious Disea,se in the Dickson Mounds Population.Medical College of Virginia Quarterly. 14: 1 7-23.MacCallum. W.G. 1920. A Text-book of Pathology. 2d edition.Philadelphia: W.B. Saunders. Zaf;reb Pateopcithttltigy Symp. 19HH Paleopathological study on infectious diseases in Japan ? 139 Miisuhashi, K. 1958. Anthropologic Studies of the Skulls of theInhabitants of Kanto District in Japan. Journal ofthe Chiba Medi-cal Society. 34:248-283.M0ller-Christcnsen, V. 1964. Evidence of Leprosy in Earlier Peo-ples. In D. Brolhwell and A.T. Sandison. eds. . Diseases in Antiq- uity. 295-306. Springfield, 111.: Charles C Thomas.Morse, D. 1961. Prehistoric Tuberculosis in America. AmericanReview oj Respiratory Disease. 83:489-503.Ogata, T. 1972. Paleopathological Studies on the Ancient JapaneseSkeletons. Nii^ata Medical Journal. 86:466-477.Ortner, D.J., and W.G.J. Putschar 1981. Identification of Patho-logical Condition in Human Skeletal Remains. Smith.wnian Con-tribution to Anthropology. 28. Washington. D.C.: SmithsonianInstitution Press.Putschar, W.G.J. 1966. Problems in the Pathology and Paleopathol-ogy of Bone. In S. Jarcho, ed.. Human Paleopalholoi^y. 57-65.New Haven, Conn.: Yale University Press.Steinbock, R.T. 1976. Paleopathological Diagnosis and Interpre-tation?Bone Diseases in Ancient Human Population. Spring-field, III.: Charles C Thomas.Stothers, D.M., and J.F. Metress. 1975. A System for the Descrip-tion and Analysis of Pathological Changes in Prehistoric Skel-etons. Ossa. 2:3-9.Suzuki, H. 1963. Human Skeletal Remains of the Ancient JapanesePopulation. Tokyo: Iwanami-Shoten.Suzuki, T. 1978. A Paleopathological Study of the Vertebral Col-umns of the Japanese from Jomon to Edo Period. Journal of theAnthropological Society ofNippon. 86:321-336.? . 1984a. Pa-leopathological and Paleocpidemiological Study of OsseousSyphilis in Skulls of the Edo Period. University Museum. Univer- sity of Tokyo Bulletin. 23:1-48. 1984b. Paleopathological Study on Osseous Syphilis inSkulls of the Ainu Skeletal Remains. Ossa. 9-11:153-168.1984c. Typical Osseous Syphilis in Medieval Skeletal Re-mains from Hokkaido. Journal ofthe Anthropological Society ofNippon. 92:23-32.1985a. Paleopathological Diagnosis of Bone Tuberculosisin the Lumbosacral Region. Journal of the Anthropological So- ciety ofNippon. 93:381-390.1985b. Paleopathological and Paleocpidemiological Stud-ies on the Human Skeletal Remains from Hokkaido and SakhalinIslands. Journal of the Anthropological Society of Nippon.93:216.Suzuki, T., and J. Ikcda. 1981. A Paleopathological Study ofCraniosynostosis-A Case of Plagiocephaly. Journal of the An-thropological Society ofNippon. 89:479-492.Tashiro, K. 1982. Paleopathological Study of Human Bones Exca-vated in Kyushu, Japan. Nagasaki Medical Journal. 57:77-102.Wada, J. 1975. Study of Changes in the Vertebral Bodies of Japa-nese with the Advance of Age. Sapporo Medical Journal,44:139-152. Summary of audience discussion: Historical records suggest ve- nereal syphilis was introduced into Japan from China in 1512, arecord consistent with the absence of treponemal lesions in the series reported here from Japan's Jomon period. Tuberculosis is notidentifiable in these series until after the Jomon period either. TheJomon people had no or few domestic animals. Zagreb Paleopathology Symp. t988 Epidemiological aspects of paleopathology inDenmark: Past, present, and future studies Pia Bennike r aleopathological studies have been carried out in Denmaricthroughout the last hundred years, and with a few exceptions,the developmental stages do not seem to differ much from thegeneral history of paleopathology known in other countries.The three stages are: the descriptive stage, the epidemiologi-cal stage , and the analytical stage . The number and subject ofthe studies within each stage may vary considerably, depen-dent on the time and the traditions of the geographical area.Some of the early Danish studies of epidemiologicalcharacter have obtained international interest. This is due toseveral factors, one of them being the long archeologicaltradition in Denmark resulting in a well-documented skeletalcollection with reliable datings. In large parts of Denmark the soil contents provide extremely good conditions for the pres-ervation of bones, and many Danish skeletons and bogbodies have been known to a wide audience, owing to themany details which could be studied. The size and the rela-tive homogeneity of the Danish population is also very suita-ble for studies of epidemiological aspects. Finally, an impor-tant factor is the role of the investigator, which must not beforgotten.In the following pages, we give a short presentation of themore important Danish studies dealing with paleopathologyfrom past and present. Together they show the development,but also the restrictions, of this topic in Denmark over theyears. We then discuss the results of the different studies inrelation to the planning of future projects. PastAs paleopathological studies in Denmark are mainly depen-dent on remains of human bones, the history can naturally notbe traced farther back than to the establishment of the skeletalcollection.In an 1837 publication the Danish scientist Eschricht re-quested that more skeletal material be preserved during ex-cavations. At that time the number of prehistoric skulls couldbe counted on the fingers of one hand. Eschricht's interest inacquiring more skeletal material was based on his wish to testcertain theories concerning the Danish prehistoric popula-140 tion. Several scientists had proposed that the ancestors of theScandinavian people may have been either Eskimos or per-haps Lapps, and this hypothesis could only be tested bystudying a larger number of skulls (Nilsson 1838; Eschricht 1 84 1 ). The theories were based on a study of very few skullswith some eskimoid traits, but later studies showed that thosetraits were not common in most skulls and may be consideredas an isolated variation. It also demonstrates that the smallerthe volume of material studied, the easier it is to draw con-clusions. This is the case in studies of both physical an-thropology and paleopathology. Whether the subsequent in-crease in the number of recovered prehistoric skulls was dueto Eschricht's request or was a natural result of the devel-oping scientific interest in anthropology at the time is notknown.By the time the German professor Virchow in 1870 visitedCopenhagen to study the Danish Neolithic population, morethan 50 skulls were available (Virchow 1870). As most scien-tists of that time, Virchow focused on questions of normalvariation and racial types and not on pathological conditions,but from that time on skeletal material was available forpaleopathological studies. The studies of the period on paleo-pathological aspects were, however, few and the topics weremostly restricted to mere descriptions, often of lesions, in-fections or trepanations on single finds (Engelhardt 1877;Hansen 1889,1913; Kjaer 1912; Nielsen 1911).At an international conference in France in 1867 Brocademonstrated that traces on a Peruvian skull, previously in-terpreted as a lesion caused by a wound, were probably due totreatment, the so-called trepanation (Broca 1867). It is notdifficult to imagine how exciting it must have been to theparticipants of that conference to look for similar cases intheir "own" collections after their return. Several studies ontrepanation were published in the years shortly after Broca'spresentation , showing that at least some of his colleagues hadsuccess in "discovering" skulls with evidence of trepanation(Hansen 1889,1913; Nielsen 1911).Toward the end of the last century, a tradition of sending skeletal material from excavations to the Institute of Anat-omy in Copenhagen was established. Usually the old bones Zagreb Paleopathology Symp 1988 Epidemiological aspects of paleopathology in Denmark ? 141 were not paid much attention there, but professor of anatomyDr. Fr. C.C. Hansen was one of the few who became inter-ested in physical anthropology. He was a coauthor of Cra/i(?Groenkmdica (Furst and Hansen 1915) but is probably bestknown in the paleopathological world for his work on theremains of 25 skeletons of Norsemen excavated at Herjolfnesin Greenland (Hansen 1924).From written sources we know that the Norsemen settledin Greenland in the middle of the 10th century, but we alsoknow that they perished for some reason, probably during the15th century. Theories on their disappearance have been pro-posed, such as: the Norsemen were killed by the Eskimos,the Norsemen may have become assimilated with theEskimos, the Norsemen may have sailed away, or the Norse-men died from starvation. In spite of several studies, it isinteresting that nobody has ever been able to confirm any ofthe theories and no satisfactory explanation has ever beenadvanced of how the medieval Norse settlers in Greenlandperished. On the contrary, several findings from studies ofthe Norsemen's environment have shown that none of thetheories above can stand alone.After studying the skeletons from a churchyard at Her-jolfnes in the older East settlement of Greenland, Hansen,however, drew the provoking conclusion that the Norsemenbecame extinct owing to inbreeding. His conclusion wasbased on the appearance of minor skeletal changes suchas osteophytes, caries, paradontosis, and similar changes "commonly" seen in paleopathological studies. A pelvicbone according to Hansen was marked with rachitic changesbut Fischer-M0ller ( 1942) later demonstrated that it was sobadly damaged and deformed by postmortem changes in thegrave that no clear conclusions could be drawn on the basis ofthis material. From an anthropometric point of view, Hansenfurthermore based his conclusion on the small stature andalso the relatively small volume of the skulls.All the single cases on which Hansen based his theorywere later reexamined by Fischer-M0ller, who also studiednewly excavated skeletons of Norsemen from Greenland.Fischer-Mrtllerwas able to reject almost ail the cases. Contr-ary to Hansen he did not find any evidence of abnormaldegeneration as a result of inbreeding. It would be too exten-sive to go into the details of Fischer-M0ller"s rejection of thesingle cases here. A repetition of Hansen's concluding re-marks would probably be useful in showing today's pal-eopathologists how dangerous it can be to draw conclusionsfrom paleopathological studies without having long experi-ence in studying skeletal changes and without having anycomparative studies to lean on, in order to learn whichchanges are common and which are not. Hansen wrote: The vigorous northern race that originally colonized Green-land degenerated in the course of the centuries under the in-fluence of the hard and at last constantly deteriorating lifeconditions and other unfavorable conditions, especially iso-lation both intellectually, materially and as regards race Zaf^rrh Paleopathology Symp. I9HH hygiene. It became a race of small people, frail, physicallyweakened, with many defects and pathologic conditions.That a race so small in number, so weakened both by in-ternal and extemal unfavorable life conditions has neverthe-less been able to stay so gallantly at its post so long, muchlonger than was before conceived possible, speaks highlyof the original quality of the race.In the fight the Norse must no doubt have been superiorto the Eskimos, but the descendants of the people who sailed "westward on the sea" in small open boats and set-tled on the inclement shores of Greenland, defying naturethrough centuries, often at war with one another, did notsuccumb in struggle with men alone. Against constantlymore severe physical conditions, against cold and a slowperiodical starvation and in greater and greater isolation thenorthem race could not at last defend itself. Influences ofnature which slowly and insidiously through the short life-time of several generations undermined the vitality of therace itself could in the long run only be conquered by helpfrom the main country and by an inflow of fresh blood togive vitality to the enfeebled race. . . . This did not hap-pen. ... Its doom was sealed by the ice of Greenland.(Hansen 1924:520-521) The basis of this conclusion may be due to the investiga-tor's poor knowledge of what is normally seen of so-calledpathological changes in skeletal studies. If Hansen was rightin his interpretation based on less severe degenerative traitssuch as osteoarthritis, the whole human race should havebecome extinct thousands or maybe millions of years ago.Almost all adult skeletons show evidence of osteoarthriticchanges.When most paleopathologists first started the study of hu-man skeletons, they probably remember how often they be-came excited by bones with pathological changes, whichlater turned out to be quite common and almost within theframe of normality. It is probably evident to all that the studyof paleopathology demands both long experience and an ex-tremely wide knowledge of the nonpathological variations.Most colleagues of anthropology are specially trained in thisfield and are familiar with the literature available. If we wantto exclude mistaken conclusions such as those Han.sen drew, it is necessary to develop a strong and wide collaborationbetween the anthropologists who have long experience inskeletal studies and the specialists of the different medicaltopics. It must be admitted that most anthropologists working inthe field of paleopathology arc clearly somewhat restrictedin their studies because of their relatively small experience inmodem anatomy and pathology. A collaboration with expertsin some medical fields is therefore highly recommended. Itis, however, not always a pathologist who is needed. Some-times a specialist in orthopedic surgery, a clinical radiologist,or a dentist may be the best person to involve in the differentcases. 142 ? Pia Bennike If we look at the epidemiological aspect of the past, studiesof this kind already began in Denmark with the previouslymentioned work on Norsemen by Hansen ( 1924), but it wassoon followed in 1936 by a study of 400 medieval skeletonsexcavated at 0m monastery (Isager 1936). Isager, who exam-ined the bones, had a medical background as a general practi-tioner and was naturally most interested in describing theunusual pathological finds. Without having contemporarymaterial for comparison his study was mainly a description ofthe pathological appearance of single bones. He also countedthe number of bones with different kinds of defects, for ex-ample bones with evidence of healed fracture. However hedid not count the number of normal bones, so no frequenciesof the pathological changes in this material are known. Epi-demiologically the study is therefore of limited value, butcontrary to Hansen, Isager was aware of not going to ex-tremes in his interpretation of the results before he had com-parative material.In the following decades the works of M0ller-Christensentotally dominated the field of paleopathology in Denmark(1953, 1958. 1961, 1963, 1967, 1978). Moller-Christensenstarted his activity in 1935 by excavating more than 700medieval skeletons at /Ebelholt monastery on Zealand(M0ller-Christensen 1958). He mainly studied the manypathological changes, which resulted in an excellent and use-ful publication, which unfortunately to date has been pub-lished only in Danish. The book contains tables with frequen-cies of almost all kinds of pathological changes seen in themedieval skeletons, and the results can therefore be com-pared to all later results of paleopathological studies. Thismakes the book on the skeletons from yCbeiholt monasterymuch more useful than the one based on the skeletons from0m monastery. It is also interesting to see the difference inthe number of diagnoses mentioned in the two studies byIsagerandM0ller-Christensen. The number of different diag-noses is quite small in the book by Isager, while M0ller-Christensen mentions more than three times as many. Thismay primarily be owing to the different years in which thestudies were carried out and to new methods developed dur-ing the second half of this century, which allowed moreprecise diagnoses to be made and described.After M0ller-Christensen finished his study on diseases inthe Middle Ages based on the many skeletons from /Ebelholtmonastery, he carefully planned his next study. One of the/Ebelholt skeletons had shown some changes that might havebeen caused by leprosy. During his search for comparablebones affected with leprosy he realized that very little wasknown of skeletal changes due to this disease. He thereforedecided to elucidate this topic. From historical records it wasknown that the so-called St. George houses were scatteredthroughout Denmark during the Middle Ages. People af-fected with leprosy were forced to live there for the rest oftheir lives, separated from their friends and families. M0ller-Christensen succeeded in locating the place where one ofthese houses and the surrounding graves were situated. After acquiring permission to start excavating the graves in1941 , more than 200 skeletons were recovered. This materialmade it possible for the first time to study changes in bonedue to leprosy on the basis of several hundred skeletonsaffected with the disease. This was indeed a collection ofhigh value for paleopathological studies (M0ller-Christensen1961,1967,1978). M0ller-Christensen's exceptional studymade it possible to add new points to the clinical diagnosis ofleprosy. The typical changes of the maxilla and of the nasalaperture with the loss of the nasal spine had not been de-scribed in skeletons before. His studies may also in an inter-national sense be labeled as unique. Often our studies inpaleopathology are restricted by a small sample size or mate- rial somehow selected to produce underrepresentation of cer-tain age or sex groups. In such cases its epidemiologicalvalue may be questioned. Sample size was not the problem inM0ller-Christensen's material from the leprosarium. Theskeletons excavated at Nsestved are naturally not representa-tive for the average medieval population, but together theyform an interesting group consisting of those who were ex-pelled from the normal community because of a specificdisease. The study of this group was the aim of M0ller-Christensen's work.In recent years a new group of skeletons of several hundredindividuals from almost the same area and period has beenexcavated. Future detailed studies will show whether themedieval people from Nasstved really managed to diagnoseand expel all those affected with leprosy. M0ller-Christensenfound that about 80% of the skeletons from the leprosariumshowed some of the characteristic changes in bone due toleprosy, whereas this author, in a preliminary study of theskeletons from a common cemetery within the town, did notfind any changes due to leprosy in the skeletons.Today, when Acquired Immunodeficiency Syndrome(AIDS) seems to threaten the modem world's population andthe discussions of how to prevent and restrict contaminationare varied and often heated, it is interesting to go back 600-700 years to see what happened in a somewhat similar situa-tion. At that time people who were suspected of having lep-rosy were doomed to spend the rest of their lives isolated inthe St. George houses, and it is the remains of those peoplewe are able to study today. Today leprosy is almost extinct inthe West, but is still known in many developing countries.From modem studies we now know that leprosy is nothighly infectious, and it is not necessary to force the affectedpeople to live their whole lives isolated and expelled from thecommunity; they can lead a normal life (Kom 1982). The bestway to prevent the disease is to provide better living condi-tions. In a very poor area in Norway the disease disappearedonly in the beginning of this century. The medieval people atthe leprosarium seem to have suffered not only from thedisease but also from condemnation by healthy people whowanted to protect themselves. Let us not repeat this mistakeby isolating those affected with AIDS. In this case the bonesof the dead may teach the living what should NOT be done. Zagreb Paleopathology Symp. 1988 Epidemiological aspects of paleopathology in Denmark ? 143 Present Within the last decade several studies on different pal-eopathological aspects have been carried out, and several reports on dentition (Lunt 1978) and cervical changes of theback in relation to dental abscesses (Ingelmark 1956) havebeen based on the medieval skeletons from yCbelholt monas-tery.A very interesting study was also carried out by Andersen ( 1 969) who compared the skeletal changes of the medievalskeletons from Nsstved with people affected with leprosy inliving populations from India.Smaller studies of pathological changes found on mainlynewly excavated skeletons have continuously been pub-lished.A recent study by the author was primarily based onDanish prehistoric skeletons and seems to constitute an addi-tional step in the development of pathological studies onepidemiological aspects (Bennike 1985). As an importantf)oint, the study provided us a catalogue of information on thedating of all Danish prehistoric skeletons available for futurestudies of paleopathological aspects. This introductory partof the study was based on an archeological/anthropologicalcollaboration which later resulted in several joint publica-tions of some of the special finds (Bennike and Ebbesen1986; Bennike et al. 1986). As a part of the work on thepaleopathology of prehistoric skeletons all bones were regis-tered in a computer system containing changes of patholog-ical, traumatic, or degenerative character of the joints, thelong bones, the irregular bones, and the skull. The many results have provided us with incidences of a number ofpathological changes, comparative analysis of the resultsbetween different groups (age and sex) and between the pre-historic periods. This may be very useful in the planning offuture studies in paleopathology of epidemiological and ana-lytic character. Future Shortly, we will begin a study of epidemiological aspectswhich may be considered a development and continuation ofthe previous paleopathology study of Danish skeletons men-tioned above. The title of the new study is: " A comparativeanalysis of methods to study nutritional and/or age depen-dent changes of the skeleton." The applied methods willinclude measurements of bone mineral content (BMC),osteon-analyscs (individual age determination), radiography(proximal femur spongiosa, Harris' lines), and finally themeasurement and weight of a removed bone core (os-teoporosis). With regard to the dentition, the presence ofenamel hypoplasia and paradontosis will be registered. Thestudy may be divided into three steps: a test of the appliedmethods by the dissection of material of known age and sex,an analysis of possible correlation between the results of thedifferent methods applied, and finally a discussion of the '/jignb Paleopathology Symp. 1988 State of nutrition and the onset of aging in prehistoric man,based on the results of the study.With regard to the chemical analyses, especially the BMC, a control study of possible correlation between the content ofcalcium in the surrounding soil and in the bones will beperformed. The skeletal material forming the basis of thisanalysis has been carefully selected. Most of the well-preserved skeletons were recently recovered in graves fromthe Viking period, and most skeletons were studied in situ bythe author. Conclusions The Danish paleopathological studies of the past , present andfuture together form a developmental pattern of three stages:the descriptive, the epidemiological, and the analytical. Inthe years of the establishment of a Danish skeletal collectionthe pathological studies could naturally only be of a purelydescriptive character. At that time nothing more could actu- ally be done owing to the small number of bones available,often from different locations. The lack of comparative stud-ies has also been a very important factor. In addition, mostscholars had only a restricted experience in studying humanbones and especially bones several thousand years old.Skeletal samples of a considerable size from the sameexcavation and site were later recovered allowing new kindsof paleopathological studies emphasizing epidemiologicalaspects. They were, however, still restricted to a presentationof tables of incidences of pathological skeletal and dentalchanges. The danger of making analytical studies and inter-preting the results at that time, without having comparativestudies available, is clearly seen in the conclusion stated byHansen as a result of his study of the Norse skeletons fromGreenland.The almost contemporary work of Isager on medievalskeletons from 0m monastery has not been of much value tolater studies either, but he did not draw any false conclusions.A new type of investigation started with the epoch of themany studies by M0ller-Christensen. His registration formsclearly show a new kind of development of the paleopatho-logical aspects. Systematically and in detail he registeredboth the normal and the pathological parts of the bones.There are several reasons why his work on the skeletons ofmedieval people affected with leprosy has been so highlyacknowledged on the international stage: his systematicwork, his comparison with studies of modem populations,and finally his well-planned projects. As one of very fewscholars of paleopathology he also succeeded in transferringhis results to clinical medicine. The facial changes of theskeletons affected with leprosy turned out to be useful in clinical diagnosis of the disease.Today almost 90% of all excavations take place withoutextensive planning because of the construction of new roadsor buildings. The skeletal material is recovered by chance,and it is almost impossible to determine which skeletal 144 ? Pia Bennike samples should be studied next. In the days of M0ller-Christenscn he was able to plan his future studies even beforethe skeletons had been located. Real epidemiological studiesallowing comparative analyses of results between differentgroups and periods first appeared in Denmark with some ofthe works of Moiler-Christensen on medieval skeletal mate- rial. Recently the paleopathological study of prehistoric skel-etons by the author has followed this tradition.The development of paleopathological studies ought not,however, to stop here, but the current database should ratherbe considered a necessary platform for new investigationsusing modem methods developed for paleopathology.A future study of prehistoric Danish skeletons has beenplanned mainly by the author, but many scientific specialtiesare included, and will result in an extensive collaborationwith other scholars in this interdisciplinary project. Scholarsfrom many different areas will be involved, mainly within themedical faculty. Other future works will probably also bemarked by much more developed teamwork between schol- ars of different specialties, allowing more detailed methodsto be presented and evaluated critically.Studies based on interdisciplinary cooperation have al-ready been common in archeology for several years. Anincreasing number of scholars, mainly of natural sciences, are involved in solving the many problems of prehistoricman's culture. In teamwork of this kind archeologists arenaturally placed in the center, being those who gather thethreads and synthesize the whole.Similarly anthropologists usually have an education ex-tending over a rather broad spectrum which may place themnaturally in the center of specialists from different areas ofmedical, dental, paleontological, and chemical disciplines instudies dealing with problems of prehistoric man's biology.Thus, the future of paleopathology may prove to be verypromising. Literature cited Andersen, J.G. 1 969. Studies in the Medieval Diagnosis ofLeprosyin Denmark, Copenhagen: Costers Bogtrykkeri.Bennike, P. 1985. Palaeopathotogy of Danish Skeletons. A Com-parative Study ofDemography, Disease and Injury, Copenhagen:Akademisk Forlag.Bennike, P., and K. Ebbcsen. 1986. The Bog Find from Sigersdai.Journal of Danish Archaeology, 5:85- 1 15.Bennike, P., K. Ebbcsen, and L. Bender J0rgensen. 1986. TwoEarly Neolithic Bog Skeletons from Bolkilde. Antiquity, 60: 199-209.Broca, P. 1867. Cas Singulicr dc Trepanation Chez les Incas. Bul-letins el Memoires de la Societe d'Anthropologie, 2:403-408.Engelhardt, C. 1877. Skeltgrave paa Sjxlland og det 0stlige Dan-mark. Aarh0ger for Nordisk Oldkyndighed og Historie, 347-402.Eschricht, D.F. 1837. ()m Hovcdskallcme og Benradenc i voregamic Gravh0je. Dansk Folkeblad. 3:109-1 16. 1841. Det kongelige Videnskabernes Selskabs Afhand-linger, 8, del 55.Fischcr-M0ller, K. 1942. The Mediaeval Norse Settlements inGreenland. Anthropological Investigations. Meddelelser omGronland, 89(2). Copenhagen: Reitzels Forlag.Fiirst, CM., and Fr. C.C. Hansen. 1915. Crania Groenlandica, ADescription of Greenland Eskimo Crania. Copenhagen: A.F.Host and S0n.Hansen, Fr. C.C. 1924. Anthropologia Medico-Historica Groen-landix Antiquae I. Herjolfnes. Meddelelser om Gronland,67:293-547.Hansen, S. 1889. Om forhistorisk Trepanation. Aarb0gerfor Nor-disk Oldkyndighed og Historie. 1 70- 1 85 . 1913. Primitiv Trepanation. Medicinsk HistoriskeSmaaskrifter. 5. Copenhagen: Wilhelm Trydes Forlag.Ingelmark, B.E. 1956. De Funktioneltt Anatomiska Forhdllandena i Ryggraden med Sdrskild Hiinsyn til dess Smdleder. Gothen-burg, Sweden: Goteborg Univcrsitels Arsskrift.Isager, K. 1936. Skeletjundene ved0m Kloster, Copenhagen: Levinog Munksgaard.Kja;r, H. 1912. Et markeligt arkaeologisk-antropologisk fund fraStenalderen. Aarbogfor Nordisk Oldkondskabs Historie, 58-72.Kom, J. 1982. Rehabilitering af Leprapatienter. Ugeskrift forLceger, 50 1 . Lunt, D.A. 1978. Molar Attrition in Medieval Danes. In P.M.Butler and K.A. Jowsey. eds.. Development, Function and Evo-lution of Teeth. London: Academic Press.M0ller-Christensen, V. 1953. Ten Lepers from Niest\'ed in Den-mark, A Study ofSkeletonsfrom a Medieval Danish Leper Hospi-tal, Copenhagen: Danish Science Press.1958. Bogen om ALbelholt Kloster. Copenhagen: DanskVidenskabs Selskab.1961. Bone Changes in Leprosy. Copenhagen: Munks-gaard. 1963. Skeltfundene fra St. J0rgens Kirke i Svendborg.Fynske Minder, 35-69.1967. Evidence of Leprosy in Earlier Peoples. In D.R.Brothwell and A.T Sandison, eds.. Diseases in Antiquity, 295-307. Springfield, 111.: Charles C Thomas.1978. Leprosy Changes in the Skull. Odense, Sweden:University Press.Nielsen, H.A. 1911. Yderligere Bidrag til Danmarks Stenalder-folks Anthropologi. Aarb0gerfor Nordisk Oldkyndighed og His-torie. 81-205.Nils.son, S. 1838. Skandinaviska Nordens Ur-lnvdnare . 1st edition,2-16.Virchow, R. 1870. Die altnordischen Schiidel zu Kopcnhagen. Ar-chivfiir Anthropologie. 4:55-91. Summary of audience discussion: A Yugoslav (Serbian) physi-cian was actually the first to describe the destructive nasal lesions ofleprosy, reported in 1 904 at a Berlin symposium and published in anobscure circular from that meeting. The theory altribuling the talc ofthe southern Greenland colony of Norsemen to assimilation withEskimos is not supported by physical evidence of dental traits ormandibular torus frequencies, but it could be evaluated further bytesting the blood group pattern in the skeletal remains and compar-ing them with appropriate English, Danish. Norwegian, and Es-kimo population samples. Zagreb Paleopalhology Symp. 1988 Human skeletal pathology in pre-Columbianpopulations of northern Chile Juan R. Munizaga Pre-Columbian populations on the arid coast of northernChile succeeded in surviving during thousands of years in avery inhospitable environment and under strong selectionpressures. Since diseases are one of the forces through whichsuch pressures act, we may be able to detect them by theanalysis of injurious effects left in the human skeletal re-mains.However, two great difficulties arise when studying thebone pathology of former populations of the Chilean aridcoast. On the one hand, we know that those populations werenever numerous and that most of their cemeteries have beendisturbed. For these reasons it may be difficult to obtain anadequate sample. On the other hand, the bone reaction todisease is limited in variability and the types of injurious effects we found may not be identifiable with respect to etiology. Therefore, the knowledge we have of diseases insuch populations is likely to remain incomplete for sometime.One way to overcome these difficulties consists in analyz-ing the human skeletal remains available using an ecologicalapproach, in which we try to establish the reactive patterns ofbone caused directly by environmental stimuli. For the popu-lation under study, the health level will be primarily definedon the basis of the potential bone deterioration caused bythose kinds of stimuli and the age attained by the individualssurviving in that environment. From this point of view, wetried to assess the health level of populations that lived on the arid coast of Chile and from which we have only a smallnumber of skeletal remains. The sample and its ecological background The specimens used in this study constitute a sample of hu-man skeletal remains from populations which lived in a frag-ile, ecological balance on the arid coast of northern Chile.They were collected by L. Nunez ( 1971 ) during his excava-tions at the mouth of the Loa River and neighboring coves.The sample is made up of at least 50 individuals representedby skulls and a lesser number of bones from the remainingpart of the skeleton, all of which are in different degrees of /4igrrb Paieopatbohgy Symp. 1988 conservation. Most of them belong to immediately pre-Spanish periods. A very small number come from periods ofabout 2000 years ago.From a morphological point of view, the population corre-sponds to a Mongoloid population living on such a coastduring several thousands of years, which occasionally re-ceived small migrations or visits from individuals comingfrom inland regions from both the Andean range of moun-tains and the Amazonian jungle.Two components of the physical environment must bedistinguished. On the one hand, a narrow, coastal band,bounded inland by a chain of steep but low hills and the vastAtacama Desert that isolated it, is characterized by its ex-treme aridity (less than 5 mm of rainfall per year) and lack ofvegetation. Its climate is humid due to "evaporation from thesea blown inland by the prevailing coast winds which isturned into mist by condensation when passing over the coldHumboldt current. In winter, this mist is left on the coastlinehills, thus keeping a high degree of humidity in the atmo-sphere" (Weiss 1951:151). Water for drinking comes fromhighly brackish springs or "aguadas," whose solid concentra-tion ranges between 8.3 and 16.0 g/1 versus drinking waterwhere the maximum is 0.5 g/1 (Lagos 1980:40). On the otherhand, an offshore sea current is full of fish, shellfish, andmammals which, considered as food resources, are enoughto support a great number of individuals.During several thousands of years, these populations kepton improving their cultural adaptation in such a way that inthe late period, from which come most of the human skeletalremains here analyzed, they had attained an efficient naviga-tional expertise. Moreover, they mastered swimming anddiving. This, added to their fishing or hunting food collectionand preservation techniques, enhanced the groups" survival.In spite of that, evidence in the archeological, ethnograph-ic, and historical data as well as chroniclers' and travelers'statements suggest that the ecological balance was unfavor-able for the pre-Columbian people who lived in small num-bers in that coastal area. During the time of the Spanishcontact, various epidemic diseases affected their popula-tions, which in time disappeared. 145 146 ? Juan R. Munizaga MethodsOur purpose was to detect the greatest number of injurious effects allowed by the examination techniques applied. Weoriented our examination along two main lines: ( 1 ) patholog-ic conditions described by other authors, considered as com-mon in the pre-Columbian populations in America (Hrdlicka1914; Stewart 1979:271; Weiss 1958); (2) possible effectsthat can be caused by pressures on a sp)ecific ecosystem. Inour case, we think that the most aft'ected apparati and systemsmay be the following:Cardiorespiratory system. Pressures upon this system areexerted through the humid environment produced by thecoastal morning mists and the dust raised by the wind, which affect the respiratory tract of children and adults (X. Vivan-co, pers. comm. ). Apnea and fast decompression during div-ing may cause serious health problems among fishermen ofthe coastal area up to the present (Bittmann 1986:54).Locomotor}' apparatus. The physical effort made in swim-ming, rowing, and diving, as well as in fishing, hunting, andfood collection and transport, placed the locomotory appara-tus under almost perpetual stress. We will use the degenera-tive changes that may have occurred in the joint surfacesinvolved in these actions as indicators of its effect.Digestive system and water and salt balance. In this case,pressures were made by the consumption of food with abra-sive (sand) and toxic elements, such as mammal liver andfish rich in vitamin A (Bamicot and Datta 1956:525), inaddition to the ingestion of brackish waters. The indicators oftheir action will be wear and the loss of teeth in addition toinfectious disease and metabolic bone alterations.The presence of disease was determined through inspec-tion, palpation and x-rays (Harris" lines).The degree of degeneration of joint surfaces was diag-nosed by the presence of lipping, erosion, and ebumation.The first was scored according to the degree of developmentof osteophytes, and the last two, on the basis of the extent ofthe destruction produced in articular surfaces (Stewart 1969;Ortner 1968; Yamaguchi 1984).Age determination was based on fusion of epiphysial andcranial vault sutures. For this purpose skulls were classifiedin the following categories: Adult 0, vault sutures open,basioccipital synchondrosis closed; Adult 1, outer sutureopen, inner suture in the process of closing; Adult 2, outerand inner sutures closing; Adult 3, outer and inner sutures inadvanced stage of closure. Results I classify three groups of stress according to their frequencyand to the knowledge we have of their causes: Group 1, a setof signs corresponding to reaction patterns deriving fromwell known environmental stimuli common to the whole population; Group 11, signs whose causes are known but theirfrequency is low; Group 111, signs whose causes are unknownbut that appear somewhat frequently in this population. GROUP ILOCOMOTOR APPARATUS AND PHYSICAL EFFORT. The effortmade in swimming, rowing, diving and getting food in thisenvironment forced the individuals of this population to stress their joints, which led first to a plastic response, whichenabled them to increase their motion capacity through thecreation of new joint facets or the extension of the normalones. However, on occasion the stress was too strong, caus-ing the progressive destruction ofjoint surfaces. It should benoted that the highest degree of destruction is found in thenewly formed joint facets (excepting the front tibial facet)and then the facets of the elbow and knee joints. This findingis in agreement with that of other authors such as Stewart(1969), Jurmain (1977,1980), and Yamaguchi (1984). Myfindings are shown in Table 1 . MASTICATION APPARATUS AND FOOD. As a rCSUlt of chCwinghard food containing abrasive elements, a clear, reactivepattern is observed which, through wear, caries and frac-tures, leads to a completely edentulous status. In most cases,compensating phenomena, such as secondary dentine forma-tion, do not compensate for the wear. Compensating mecha-nisms are also hampered by infection which, through the roots, causes periapical problems leading to the destructionof alveolar bone. In addition, owing to the loss of the backteeth, the front teeth are subject to greater use, so that thetemporomandibular joint receives abnormal stress, some-times giving rise to the degeneration of the joint surface. Myfindings are shown in Table 1 . GROUP IIOwing to the variety of features found in this group and totheir low frequency, we give some details of each case. Fre-quencies are shown in Table 2.Harris' lines. The average number of growth arrest linesobserved per tibia is 1 . 1 and the percentage of affected tibiaein the population is 40.0. These values are similar to thosefound for pre-Columbian populations in the northernmostChilean coast (1.5 and 35.6% respectively), but they aredifferent from those occurring in the inland farming popula-tions, which show a great frequency of these lines both at anindividual and at a population level: 6.2 and 67.8% respec-tively (Allison et al. 1981:270).Hypoplastic lines ofenamel. Though we established theirpresence in several individuals, we could not determine theirfrequency due to the high rate of postmortem loss of teethfound in this population sample. Zagreb Paleopathology Symp. 1988 Human skeletal pathology in pre-Columbian populations of Chile ? 147 Table 1. Injurious effects and reactivepatterns of mastication and locomotorapparatus Group IMA^nCATION APPARATUS Nt (%) Dental caries 148 ? Juan R. Munizaga Disc hernia? An oval defect 10 mm wide and 5 mm deepwas found in the lower face of the 1 1 th dorsal vertebra bodyand which communicated with the vertebral canal. A similarbut smaller injury was found in the upper face of the 12thdorsal vertebra body. No reactive bone formation is ob-served.Paraplegia. A symmetrical alteration in the shape offemoral diaphysis was present in a male adult in the form of a slight decrease of its diameter and several symmetrical de-pressions of oval shape and longitudinal direction. It mightcorrespond to a bone involution produced by a paralysis ofthe vastus medialis muscle, since in this individual the defectoccurred between the 11th and 12th dorsal vertebrae de-scribed above and, owing to its opening to the spinal canal, itmight have involved the lumbar plexus, whose upper fibersinnervate that muscle.Alterations of the lumbar column. A case of incompletesacralization of the fifth lumbar vertebra and one of trans-verse apophysis separated from the third? lumbar werefound. This diagnosis is based on the presence of slight jointfacets. Both trauma and hereditary defect are diagnostic pos- sibilities (Stewart 1969:448).Periostitis. Signs such as longitudinal striations were ob-served in long bones and, in some cases, deposits of thinbone sheets on the outer table.Generalized infection. This was found in a female adultwhose lower limb bones appear thickened with an irregularsurface.Cholesteatoma. A globular widening of the auditory canalwith a thinning of the tympanic plate (Stewart 1979:268). GROUP III Pathologic signs of this group are shown in Table 2. Injuries GROUP I The bone reactive patterns we have described are well knownand their relationship to the environment we have describedare apparent. When interpreting their elements, confusionmay arise concerning the boundaries existing between thenormal, plastic response and the pathological response. GROUP II Injuries described for this group may be analyzed under three .separate headings according to their most general causes.GROWTH ALTERATIONS. Evidence arising from Harris' linesand hypoplastic lines in the enamel of this population is rather contradictory and, based on such evidence, it would beimpossible to provide a clear diagnosis of poor health condi-tions during childhood. ACCIDENTS. The presence of traumatic accidents caused byaggression are minimal in this population, since the onlyavailable trace of intentional blows appears in an individualwhose origin must be sought in inland populations where thesigns of violence appearing in the skulls range between 4 and18% (Munizaga 1974:38). The remaining injuries falling un-der this heading seem to correspond to accidents during work activities. Thus, the rib fractures, disc herniation and associ-ated paraplegia, and even the lumbar column malformationswe have described may have these causes, as well as infec-tions whose origin seems to be located in the legs. The lattercan be understood if we remember that the highest risk wasrun by individuals of this group while sailing in rafts made ofinflated hides, their legs being the most exposed parts of theirbodies. An author who observed these rafts in 1780 tells usthat "sometimes it happens that dolphins, sharks or otherlarge fish puncture them and fishermen are left in a dangeroussituation" (Bittmann et al. 1980:70). ENVIRONMENTAL ACTION. We would have to analyze chol-esteatoma under a separate heading. Stewart (1979:268),who is perhaps the only one who has recorded it, describes apattern of differential distribution for Eskimos and Aleuts onthe one hand, among which he has recognized 15 cases, andthe more southern natives on the other hand, where he onlymentions one case coming from Peru. Based on the medicalevidence available for diseases of the ear in the present popu-lations of Alaska, he poses the possibility that this pathologiccondition might correspond to a cholesteatoma and that itmay be related to the cold weather of the Arctic region.The finding of a case in tropical latitudes is, therefore,hard to explain. Nevertheless, we have found two other casesshowing this pathological condition in pre-Columbian indi-viduals of coastal populations in the vicinity of the one wehave described (Pisagua and Cobija). Then, considering thenumber of cases examined for this area, their frequency inAlaska and the arid coast of Chile is likely to be similar. Inaddition, if we remember that the fishermen we have de-scribed dive in the waters of the Humboldt current with its characteristic low temperatures, the causal agent may also bethe same. GROUP III I am not certain about the causes of the injurious effects wehave described in this group, but various hypotheses may beposed about their origin. I think that they may be explainedby three patterns of bone reaction. Zagreb Paleopathology Symp. 1988 Human skeletal pathology in pre-Columbian populations of Chile ? 149 ALTERATION OF THE ENDOCRANIAL RETURN CIRCULA-TION. The swimming stroke used in the coastal region cons-ists of maintaining only the head outside the water. In con-trast, hunting and food collecting on land tends to direct theeyes and head downward. These head positions induce ahyperextension and hypertlexion of the occipitoatloidal jointas shown by the frequency of the third condyle and the de-generative changes in the joint surfaces of ail of them. I thinkthat these sustained and frequent movements must have hin-dered in a mechanical way the intracranial return circulation at the level of vessels and plexus surrounding the foramenmagnum. It is also possible that, during the first years of life,an internal cause has been added: brain edema. This condi-tion might be caused by the increase of intracranial pressuredue to fluid retention produced by the ingestion of brackishwater. This would alter the return circulation, as shown bythe alteration of the course of the superior longitudinal sinus(formation of an endobregmatic lagoon or cistern), whichwould be a more apparent sign (see Table 2). ALTERATION OF THE BLOOD CALCIUM LEVEL. Sudden de-compression during diving and perhaps the ingestion of food rich in calcium may have raised the level of this element inthe blood. For mechanical reasons, calcium should tend toconcentrate in the blood stasis zones of the brain and produceextravasation of the emissary vessels in the passing zones,specifically in the ectocranial surface surrounding them ontheir way out. This might explain the bone neoformationdescribed for the obeliac region and even the osteoma of theauditory meatus. THICKNESS INCREASE OF CRANIAL BONES. A bone reactionpattern which led to a thickness increase in the bones wasposed a long time ago for pre-Columbian populations in thearid coast of northern Chile, without an explanation for itscauses (Vergara-Flores 1894, 1905; Fonck 1906). Findings inthis population confirm its presence, but its frequency andintensity are lower than those established for a great numberof populations in America (Munizaga 1984:40).Various causes have been given to explain this bone reac-tion pattern: diet, such as vitamin C (Bourne 1956) and Ddeficit, hypervitaminosis A (Fonck 1906); anemia (Angel1967; Munizaga 1965); and inheritance (Weidenreich 1943).In this case, while an exaggerated thickness in reinforcementzones is likely to be explained from a genetic point of view,the increased thickness of the vault bones may also be due tothe first two already mentioned causes. It must be pointed outthat we have not found the orbital and parietal sieve platescharacterizing porotic hyperostosis. It might be that its ap-pearance was modified by the alterations of the endocranialreturn circulation appearing in this population in infancy. Thesole case we have found of sieve plates in their active phase is Table 3. Sex and age distribution on basisof skulls Group IAges Infants Males Females Total AO 150 ? Juan R. Munizaga young women observed. In other words, human skeletal re-mains of these populations in fragile balances are likely toappear rather free of pathology, since any disease may causethe death of individuals long before such disease has timeenough to attack the bone system. ConclusionsOn the basis of the bones examined, this population shows ahigh health level, characterized by a low prevalence ofchronic infections, absence of signs of violence, and a low rate of accidents. However, the following reactive patterns ofbone may be distinguished: reinforcement and deteriorationof joint surfaces, loss of teeth and periapical processes, al-terations of the endocranial return circulation, osteomas ofthe ear and the obeliac region, and increased thickness inbones. There is no doubt about the validity of the first two.The others are presented as hypotheses.However, the apparent high level of health observed in thispopulation seems to be the result of the elimination of peoplewho had difficulties in adjusting to the environment. Thiscould happen even to people affected by minor and transitorydisability, such as pregnancy. Perhaps those factors may ex-plain the limited size of these populations observed in the aridnorthern coast of Chile by travelers visiting them in the past. Literature cited Allison, M., G. Focassi, and E. Gerszten. 1981. Estudio Radi-ografico y Demografico de Morbilidad y Mortalidad de PueblosPrecolombinos de Peru y Chile. Chungara. 8:256-274. Arica,Chile: Departamento de Antropologia, Universidad del Norte.Angel, J.L. 1967. Porotic Hyperostosis or Osteoporosis Sym-metrica. In D. Brothwei! and A.T. Sandison, eds.. Diseases inAntiquity. .378-389. Springfield. III.: Charles C Thomas.Bamicot. N.A., and S.P. Datta. 1956. Vitamm A and Bone. InG.H. Boume, ed.. The Biochemistry and Physiology of Bone.507-538. New York: Academic Press.Blttmann. B . 1 986. Recursos Naturales Renovahles de la Costa delNorte de Chile. 1-66. Tokyo.Bittmann,B.,M.T. Ahumada.andN. Montenegro. 1980. ElSurgi-miento, Desarrollo, Decadencia y Abandono de Cobija-Lamar:Notas Historicas. In B. Bittmann, et a!., Cohija. Proyecto deInvestigaciones Interdisciplinarias en la Costa Centro Sur And-ina (Chile). 63-120. Antofagasta, Chile: Universidad del Norte.Boume, G.H. 1956. Vitamin C and Bone. In G.H. Boume, ed..The Biochemistry and Physiology ofBone, 251-286. New York:Academic Press.Fbnek, F. 1906. Los Crdneos dc Paredes Graesas segun VergaraRores. Un Dato Mas. Revisia Chilena de Hisloria Natural. 10.Hrdlicka, A. 1914. Anthropological Field Work in Peru in 1913,with Notes on the Pathology of the Ancient Peruvians. Smilh.\o-nian Institution Miscellaneous Collections, 61 :54-61 . Jumiain, R.D. 1977. Stress and the Etiology of Osteoarthritis.American Journal of Physical Anthropology. 46:353-365.1980. The Pattem of the Involvement of AppendicularDegenerative Joint Disease. American Journal of Physical An-thropology 53:143-150.Lagos, R. 1980. Un Estudio Geoecol6gico de la Costa deCobija; ElFactor Geomorfologicoy la Existenciade Agua. InB. Bittmann, et al. , Cobija. Proyecto de Investigaciones Interdisciplinarias enla Costa Centro Sur Andina (Chile). 3 1 -47. Antofagasta. Chile:Univcridad del Norte.Munizaga, J.R. 1965. Espongio Hiperostosis (Humpcrl y Weiss) uOsteoporosis Simetrica (Hrdlieka). Diagnostico. EpidemiologiaAntigiiedad. Revista de Antropologia, 3(1 ):39 1-394. Univer-sidad de Chile.1974. Paleoatologia Chilena. Antropologia. scgunda ep-oca, 1:35-39. Santiago, Chile: Departamento dc CienciasAntropologicas y Arqueologicas, Universidad dc Chile.1980. Restos Oseos Humanos de la Costa Norte de Chile.Analisis de Cementerios Disturbados de Cobija, II Region,Chile. In B. Bittmann, et al., Cobija: Proyecto de Investiga-ciones Interdisciplinarias en la Costa Centro Sur Andina (Chile). vol. 1, 199-216. Antofagasta, Chile: Universidad del Norte.1984. Craneos de Paredes Gmesas. Revista Chilena deAntropologia. 4:19-61. Santiago, Chile: Universidad de Chile.Nunez, L. 1971. Secuencia y Cambio en los Asentamientos Hu-manos de la Desembocadura del Rio Loa, en el Norte de Chile.Boletin de la Universidad de Chile. 3-25. Santiago, Chile.Ortner, D.J. 1968. Description and Classification of DegenerativeBone Changes in the Disal Joint Surfaces of the Humerus. Ameri-can Journal of Physical Anthropology. 28: 1 39- 1 56.Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho-logical Conditions in Human Skeletal Remains. SmithsonianContributions to Anthropology. 28. Washington, D.C.: Smithso-nian Institution Press.Stewart, T.D. 1969. The Effects of Pathology on Skeletal Popula-tions. American Journal ofPhysical Anthropology. 30:443-450.1979. Patterning of Skeletal Pathologies and Epidemiol-ogy. In W.S. Laughlin, ed.. First American: Origins. Affinitiesand Adaptations. 257-274. New York: Wenner-Gren Foundationfor Anthropological Research.Vergara Flores, L. 1894. Craneos de Indios Bolivianos. Actes So- ciete Scientifique du Chili. 4:231-250.1905. Craneos de Paredes Gmesas. (Nuevas Investiga-ciones de 63 Craneos de Quillagua y Algunos de la Costa). Re- vista Chilena de Historia Natural. 9: 172- 190.Weidenreich, F. 1943. The Skull of Sinanthropus Pckinensis? A Comparative Study on a Primitive Hominid Skull. PaleontologiaSinica. new series D, 10. Pehpei, Chungking.Weiss, P. 195 1 . Geografia de las Enfermedades en el Peru en Rela-ci6n con las Zonas Climaticas. Conferencias de CienciasAntropologicas. 140-167. Homenaje al IV Cenlenario de la Fun-dacion de la Universidad Mayor de San Marcos dc Lima.1958. Osteologia Cultural. Lima, Peru.Yamaguchi, B. 1984. Degenerative Changes in the Distal Humerusand Femur. Bulletin of the National Science Museum. 10:9-17.Tokyo. Zagreb Paleopathology Symp. 1 988 Observations on health, genetics, and culturefrom analysis of skeletal remains fromRoonka, South Australia Miroslav Prokopec and Graeme L. Pretty Site and environment The skeletal material reported here comes from the archeo-logical site Roonka Flat on the right bank of the MurrayRiver, 8 km north of Blanchetown in South Australia. Theflat has a semicircular shape, is open to the west and borderedby lagoons on the northern and eastern sides. Steep cliffs ofTertiary deposits face the flat on the opposite side of the river.The Aboriginal tribe which occupied the area at the time of itscolonization by Europeans in 1844 was known by the nameNgaiawang. Freshwater mussels, fish, marsupial game androdents and various plant foods are assumed to have formed alarge proportion of the diet of the original inhabitants. A sanddune located on an elevated place on the Roonka Flat wasfrequently used as a burial site. It is likely that it was usedalso as a camp site because of its pleasant position. Heaps ofmussel shells were found at several places.Human bones began to emerge from the soil in the early1960s following floods and strong winds. Systematic ex-cavations were commenced by one of us (G.L.P.) in 1968with the support of volunteer labor and continued until 1976.Most of the excavated graves (n = 1 1 1) come from trench A,which was laid on the top of the dune, others from trenchesOA, lA, IB, B and from the bulks between the trenches.Several skeletons were brought to the museum prior to thebeginning of systematic research. Materials and methodsCHRONOLOGY OF INHUMATIONS Carbon from the basal zone of trench A was dated 18,000years b.p. (Phase Roonka I) and carbon associated with oneof the older groups of skeletons was dated about 7000 yearsB.p. (Phase II). Intermediate group Ilia is dated approxi-mately 4000 years b.p. and the youngest group Illb is esti-mated to have terminated at circa a.d. 1850 (Pretty 1977).The site was thus used from time indefinite to the period of Zagreb Paleopalhotogy Symp. t988 European contact. Questions posed to physical anthropolo-gists were: who were the people; what did they look like;which diseases affected them and which were the most proba-ble causes of death? LABORATORY The bones available for assessment in the laboratory were ina poor state. Most of the skulls had to be reconstructed andsealed together from many fragments. Most of the skeletonswere incomplete.Analysis of human osteological remains from Roonkashowed that the same type of people occupied the flat for atleast 7000 years and made a positive contribution to archeol-ogy by throwing light upon demography, health status, cul-ture, way of life, and genetics of the past population. At-tempts were also made to evoke the appearance of someindividuals by drawing or modeling the missing soft parts onthe skull. DEMOGRAPHY Current methods described (Martin and Sailer 1957; Lamachand Freedman 1964; Hrdlicka 1947; Stewart 1952; Krogman1962;Brothwell 1963; Trotter and Gle.ser 1952) were used todetermine sex, age and stature from the bones. Pathologicalchanges in the bones were reviewed with C.L. Manock andD. Pounder (pathologists), and D. Simpson, a neurosurgeon,reviewed a special case of a complete craniosynostosis in a child. Demographic aspects were studied according to Ac-sadi and Nemeskeri (1970) and Stloukal and Hanakova(1971). Results There were 165 individuals identified in Roonka, including60 (36%) children and subadults, 58 males (35%) and 47females (29%). The mean age of all individuals buried at151 152 ? Miroslav Prokopec and Graeme L. Pretty Figure 1 . Healed fracture of femur with over- ride and slight angulation of humerus and ulna.All photographs, with the exception of Figure 2,by M. Prokopec. Roonka was about 24 years , of males over 20 years of age 36years, and of females 32 years. The mean stature of maleswas 1 67.4 cm (SD 6.1 cm), andof females was 156.5 cm (SD5.4 cm). The difference in the mean height between bothsexes amounted to 10.9 cm. The greatest mortality was inearly childhood and in the adult group between 20 and 30years of age. The least represented age groups in the samplewere children of approximately 10 years and those of thesenile group over 60 years of age. HEALTH STATUS Conclusions on general health of people once living at Roon-ka may be drawn from the age at which people died, from stature, from size and shape of bones, and from traces ofdisease on teeth, jaws and bones (Smith ct al. 1988). Thepresence of some diseases in the past population can be onlyassumed using a present day population, living in a similarenvironment, as a model.Fractured bones and skull vaults and depressions in the skull vaults are evidence of trauma (Figures 1 ,2), thoughhabits such as preventing the dead man or woman from re-turning to life by throwing stones into the grave may explainsome traumatic changes which might have been inflicted after death.A woman was buried at the moment of childbirth. A de-pression across her forehead was considered a fatal blow ? the most probable reason being euthanasia (Pounder et al. Figure 2. Skull of adult female. No. 1 10, in situin grave from trench A, Roonka, showing de-pression over frontal bone following a blow by anarrow object causing fracture. Photograph byLloyd Chilman. Figure 3. Skull of 5-year-old child with cra-niosynostosis and fracture of right temporalbone. Fine pitting on parietal and occipitalbones. Grave No. 77, Roonka. 1983). Various pathological changes were found, such as anosteoma in the mandible in an old person, premature closureof all skull sutures (Simpson et al. 1983-1984; Prokopec et al. 1985) (Figure 3), arthritic changes in joints, signs ofinflammatory processes on bones, an open sacral canal, andyaws or other trepanarid infections (Figures 2-7). It may be Zagreb Faleupulhology Symp IVSS \ Analysis of skeletal remains from Roonka, South Australia ? 153 Figure 4. Osteophytosis especially of uppermargins of upper lumbar vertebrae. Grave No.85, Roonka. Figure 6. Open neural channel in sacrum. TombNo. 61, Roonka. Male, mature. Figure 5. Compression fracture of body of T9and accentuated thorax curvature. Fusion of all units through coalescence of osteophytes and ap-ophyseal facets: T9/10, TlO/11, Tll/12 andT12/L1. Ankylosing spondylitis? Tomb No. 80,Roonka. Male, mature. Figurk 7. Lytic lesion with rugged edges and stellate scars on frontal bone due to treponaridinfection yaws? Tomb No. 18, Roonka. Male,adult. Zagreb Paleopathology Symp. I9HH 154 ? Miroslav Prokopec and Graeme L. Pretty FiGURF 8. Enamel hypoplasia in upper incisors and caninesand overbite in adult female. Tomb No. 1 10, Roonka. Figure 10. Shovel-shaped incisors and tuberculum dentaleon left central upper incisor in juvenile individual male?Tomb No. 13A, Roonka. Figure 1 1 . Compressed front teeth crowding in juvenile individualmale? Tomb No. I3A, Roonka. Figure 9. Thickening of diploe of frontal bone14 mm thick. Tomb No. 7, Roonka. Female, adult. _^_^ said that these features, present in populations all over theworld, connect the Australian Aboriginals with other popula-tions(Rochlin 1965;Sandison 1973). Evidence of nutritionaland metabolic disorders were found in some bones and teeth,such as fine pitting on the bone surface (Figure 2), enamelhypoplasia in front teeth (Figure 8), and thickening of thediploe of the frontal bone (Figure 9). GENETICS Inborn anomalies found in Roonka include supernumerarycusps on molars, shovel-shaped incisors, tuberculum dentale(Figure 10), protruding lower jaw (underbite), aplasia of lat- eral incisors, and other features. These are also found inevery population in the world, sometimes perhaps with dif-ferent frequencies.Crowded teeth in lower jaws were quite frequent (28%) inthe Roonka adult population (Figure 1 1 ). Heavy stress on theteeth since childhood may be blamed for this, since pressure acts in the direction from the molars toward the front teeth. Zagreb Paleopalhology Symp 1988 Analysis of skeletal remains from Roonka, South Australia ? 155 Figure 12. Horizontal abrasion of crowns of all teeth inmaxilla with secondary dentine. Note concavities of surfaceof tooth crowns. Tomb No. 50. Roonka. Male, mature- senile. Figure 13. High-grade attrition of crowns of all teeth inmaxilla with open root cavities of some teeth. Helicoidalform of attrition. Tomb No. 61, Roonka. Male, senile. Genetically minded dental specialists explain it by indepen-dently inherited tooth size (broad teeth) and independentlyinherited mandible size (narrow mandibles). This phenome-non discovered in the Roonka population may contribute todiscussions on the yet unknown origin of Aboriginals inAustralia. It would mean that more than one strain of peoplewere present in their ancestry?apparently a gracile and arobust type. CULTURE Culture has many facets. It is responsible for the behavior ofthe people, and to a certain extent it influences also theirbodies. In the Roonka population the following features maybe viewed as a sequence of cultural influences: deep abrasionof the crowns of the teeth (horizontal, helicoidal, interproxi-mal) (Figures 12-15), ritual evulsion of one or two uppercentral incisors (Figure 16), and ear exostosis (thickening ofthe external auditory canal bone), explained by otolaryngolo-gists as a reaction of the bone (periosteum) to cold tempera-ture and frequently found in swimmers and divers (Hrdlicka1935). It has been found in male skulls only (Figure 17).According to Campbell (1925), the habit of ritual toothevulsion existed only in North and Central Australia (Figure16). Roonka revealed that this ritual was practiced also in thesouth of the continent for thousands of years. Skulls withevulsed central incisors were found even in the oldest graves(Campbell and Prokopec 1984).Roonka showed that before Europeans came, the peoplewere probably completely free from caries. This does notmean that they did not suffer from other gingival and dentaldiseases and discomforts. The principal problems were dueto extensive abrasion of crowns. Despite the formation ofsecondary dentine which developed in the abraded parts of Zagreb Paleiipalhiilofiy Symp lyXH the crowns (Figure 18), deep abrasion led in some instancesto penetration into the tooth cavity. As a rule bacterial infec-tion followed and led to periapical inflammations and ab-scesses (Figure 19).Food preparation over an open fire (during which ashesand sand inevitably got into the food) is probably the mainreason for tooth abrasion. The habit of chewing herbs andleaves of alkaloid-containing plants mixed with ashes as wellas the presumed habit of rubbing teeth of the lower jawagainst those of the upper jaw in the absence of food couldalso hasten the process of tooth abrasion.Another important agent which leads to dental deteriora-tion is using teeth as tools in manufacturing weapons andotherobjectsofdaily use (Figure 15). Even stone implementswere sometimes retouched by teeth according to Barrett(pers. comm.) (Prokopec 1979). RECONSTRUCTION OF FACE FROM SKULLA drawing or photograph of a skull may serve as a basis fortwo-dimensional face reconstruction using the method ofGalina Lebedinskaya. In order to reconstruct the face prop- erly, the skull should be intact and complete, in particularwith respect to the preservation of the nasal bones and theanterior nasal spine (Sj0vold 1981). Any method of facialreconstruction is always associated with some inaccuracy. Itis important to make allowances and adjustments for age ofthe person in question. A method of supcrprojection of aphotograph of a man or woman belonging to the same popu-lation over a skull may show the probable appearance of thedead person. This is only the ca.se when the skull and photo-graph match satisfactorily in a .scries of well-identified an-thropometrical points on the skull and face and in a series offacial features and contours (Prokopec 1987). Photographs of 156 ? Miroslav Prokopec and Graeme L. Pretty Figure 14. Horizontal and interproximal attrition of right M 1 and M 2 in mandible, Tomb No. 87, Roonka.Female, mature. Figure 15. High-grade attrition with tilted left upperM 1 . Buccal margin of teeth is more aflected by attri-tion. Tomb No. 87, Roonka. Female, mature. Figure 16. Ritual evulsion of right upper central andlateral incisors. Healed tooth sockets. High attrition inremaining teeth. Enamel hypoplasia. Alveolar bone resorption. Tomb No. 23. Roonka. Male, mature. Zafireh Pciieopathnloi>\ Svmp. 198H Analysis of skeletal remains from Roonka, South Australia ? 157 Figure 18. Peglike right upper tliiid iiK)lar. scLoiidary dentin on thecrowns of M 1 and M 2. Tomb No. 96, Roonka. Female, mature. Figure 17. Auditor) exostosis posterior. Bothsides of skull affected. Tomb No. 3, Roonka.Male, senile. Figure 19. Considerable wear of tooth crowns with anopen pulp cavity in first left lower molar, leading to anabscess. Tomb No. 23, Roonka. Male, mature. Aboriginals from the Port Lincoln Aboriginal Reserve inSouth Australia taken in the last century were used for super-projection over some of the Roonka skulls. In one instance an oil painting of an Aboriginal chief was matched with a skullfrom one of the status graves from trench A from the RoonkaFlat. Conclusions Anthropological analyses on a sample of human skeletal ma-terial from an archeological site (Roonka) in South Australiashed light on demographical structure, health status, genet-ics, culture, and probable way of life of the people whoinhabited the site for at least 7000 years before the arrival ofthe first European settlers. The buried people belonged to abasically similar physical type throughout the time period.Three different methods of face reconstruction from skullswere used in an attempt to restore the probable appearance ofsome of the buried persons. Zagreb Paleopathotogy Symp. t9Sft Their mean stature and mean age at death are much lowerin comparison to present-day standards. On the other hand,child mortality was much higher but consistent with the so-ciety of hunters and gatherers and their harsh way of life.Women and babies were always at risk at childbirth whilemales died frequently in fights. Diseases which leave markson bones were present as in other societies, not only innomads. Fine pitting in a skull of a child indicates the pres-ence of anemia, and several instances of enamel hypoplasiabear evidence of nutritional disorders in early life. Caries was rare or absent , though deep abrasion of teeth and lack of oralhygiene caused trouble and discomfort. Contrary to literarysources the Roonka material showed that ritual evulsion ofupper central front teeth was performed in South Australiafor at least 7000 years.Survival of the Roonka population under conditions simi-lar to those faced by paleolithic hunters and gatherers forsuch a long time is the best proof of a functioning societyfully adapted to the given environment. 158 ? Miroslav Prokopec and Graeme L. Pretty Acknowledgments Grateful acknowledgment is made to the South AustralianMuseum. Adelaide, to the Australian Institute for AboriginalStudies. Canberra, and to the Institute of Hygiene and Epi-demiology, Prague, for their support, and to Lloyd Chilmanfor the photograph in Figure 2. One of the authors (M.P. ) expresses his thanks to the Smithsonian Institution, whichenabled him to study human osteological material in thecollections of the U.S. Museum of Natural History in Wash-ington, D.C. Further support to G.L.P. was provided by theAustralian Research Grant Scheme. Sir Mark Mitchel Foun-dation, Potter Foundation, Sunshine Foundation, and UtahFoundation. All specimens illustrated herein are courtesy ofthe South Australia Museum.The authors are grateful to Colin Cook. Chairman. GerardCommunity Council, and Valerie Power. Community Ad- viser, Point Macleay Community Council, for their supportto the Roonka research project and interest in its results. Literature cited Acsadi, G.. and M.J. Nemeskeri. 1970. History of Human LifeSpan and Mortality. Budapest: Akademiai Kiado.Brothweli. D.R. 1963. Digging up Bones. London: British Muse-um of Natural History.Campbell. AH., and M. Prokopec. 1984. Antiquity of Tooth Avul-sion in Australia. Artefact. 8:3-9.Campbell. TD. 1925. Dentition and Palate of the Australian Ab-original. Adelaide. Australia: Hassell Press.Hrdlicka. A. 1935. Ear Exostoses. Smithsonian Miscellaneous Col-lections. 93:1-100.1947. Practical Anthropometry, T.D. Stewart, ed. Phila-delphia: Wistar Institute of Anatomy and Biology.Krogman. W.M. 1962. The Human Skeleton in Forensic Medicine.Springfield. 111.: Charles C Thomas.Lamach, S.L., and L. Freedman. 1964. Sex Determination of Ab- original Crania from Coastal New South Wales. Australia. Rec-ords of the Australian Museum. 26:295-308.Martin. R.. and K. Sailer. 1957. Lehrbuch der Anthropologie insystematischer Darstellung. Stuttgart. Germany: G. Fischer Ver-lag.Pounder. D.J.. M. Prokopec. and G.L. Pretty 1983. A Probable Case of Euthanasia amongst Prehistoric Aborigines at Roonka,South Australia. Forensic Science International. 23:99-108.Pretty, G.L. 1977. The Culture Chronology of the Roonka Flat. APreliminary Consideration. In R.V.S. Wright. ci\.. Stone Tools asCultural Markers: Change, Evolution and Complexity. 228-331 . Canberra: Australian Institute for Aboriginal Studies.Prokopec. M. 1979. Demographical and Morphological Aspects ofthe Roonka Population. Archaeology and Physical Anthropologyin Oceania. 14:1 1-26.1987. FT)er die Rekonstmktion des Gesichtsausdruckes alter Slaven. Acta Musei Nationalis Pragae, Line B. NaturalSciences. 43:203-205. Tables 9-12.Prokopec. M.. D. Simpson. L. Morris, and G.L. Pretty. 1985.Craniosynostosis in a Prehistoric Aboriginal Skull: A Case Re-port. Ossa. 9-11:111-118.Rochlin. D.G. 1965. Diseases of Ancient Man. Moscow: Nauka.Sandison. A.T 1973. Disease Changes in Australian AboriginalSkeletons. Australian Institute ofAboriginal Studies Newsletter,3:20-22.Simpson. D.. M. Prokopec. L. Morris, and G.L. Pretty. 1983-1984. Prehistoric Craniostenosis: A Case Report. Records of theAdelaide Children s Hospital. 3:163-168.Sj0vold, T 1981. Arpas Anatomical Method for Face Reconstruc-tion. Ossa. 7:203-204.Smith. P.. M. Prokopec, and G.L. Pretty 1988. Dentition of aPrehistoric Population from Roonka Flat. South Australia. Ar-chaeology in Oceania. 23:31-36.Stewart, T.D. 1952. Hrdlicka s Practical Anthropometry. Phila-delphia: Wistar Institute of Anatomy and Biology.Stioukal, M., and H. Hanakova. 1971. Anthropology of an EarlyMediaeval Burial Site in Abraham. Acta Musei Nationalis.27B:3.Trotter, M.. and G.C. Gleser. 1952. Estimation of Stature fromLong Bones of American Whites and Negroes. American Journalof Physical Anthropology. 10:463-514. Summary of audience discussion: The tooth crowding demon- strated is interesting because Dr. Corruccini's work in India sug-gests a decreased frequency of tooth crowding in populations con-suming a diet requiring vigorous chewing, the frequency rising laterfollowing the introduction of a softer diet. No such pattern, how-ever, was demonstrable in this population. The two cranii revealingchanges suggestive of treponematosis failed to demonstrate perios- titis of the tibia or other long bones. Zagreb Paieopaihotogy Symp. 1988 Tuberculosis Tuberculosis in the Americas:Current perspectives Jane E. Buikstra and Sloan Williams Histologic studies of the hydrated lungs showed a large amount of fibrous tissuein the right apex. Dr. Garcia-Frias concluded the combination of spine and lungdisease showed that tuberculosis is the most likely diagnosis, and the present writer agrees, although other conditions cannot be ruled out. ?Morse 1961:497 The case presented herein should conclusively end this dispute and remove doubtthat tuberculosis did exist in the Department of lea in southern Peru, SouthAmerica, hundreds of years before the coming of any European to the Americas. ?Allison etal. 1973:985 Rchydrated soft tissue from South American mutnmies hasproved crucial in the ongoing debate concerning the presenceof a "tuberculosis-like" pathology in the prehistoric Amer-icas. In the 1961 review cited above, Morse, while skepticalof North American skeletal examples attributed to tuber-culosis, was willing to accept tuberculosis as "the most likelydiagnosis" for mummified Peruvian remains reported byGarcia-Frias in 1940. Even though he found the tissue evi-dence convincing, Morse (1961:497) was led to question thearcheological context for these materials and thus concludedthat a pre-Columbian attribution was not secure.Further investigations of mummified soft tissue, reportedby Allison and co-workers in 1973 and 1981 , provided con-vincing histologic and contextual data. The 1973 report de-scribed acid-fast bacilli. Pott's disease, and a psoas abscessin the remains of a Nazca child, dating to approximately a.d.700, and thus established with certainty the presence of atuberculosis-like pathology in the prehistoric Americas.Even Morse was led to alter his stance, remarking that al-though he generally agreed with Allison and co-workers con-cerning the diagnosis, "there should have been many morecases of suspect tuberculosis than have been found to date"(1978:53).Recent studies of pre-Columbian tuberculosis, as indi-cated in Table 1 , are rapidly providing the "many more cases"called for by Morse. Most examples cited in this survey aredescriptive reports of skeletal lesions from North American series, including isolated cases as well as profiles from largersamples. Both isolated examples and frequency data are im- Zagreh Pateopatholof^y Symp. 1988 portant in establishing the probable antiquity and distributionof the pathology, although for issues relating to communityhealth and quality of life, the large-scale series are most useful. In South America, Allison and co-workers (1981,1984) have documented additional cases from Peru andChile. Surveys of large Andean skeletal samples to establishlesion form and distribution in a manner suitable for com-parison with North American data sets have, however, yet tooccur. The ultimate goal of this paper is, therefore, to estab-lish lesion patterning within a large prehistoric Peruvian skel- etal sample and thus provide a data base for comparison withNorth American examples.Related topics addressed within the past few years includethe persistent question of origins. The argument that tuber-culosis could only have developed in the context of domesticanimals as hosts (Cockburn 1963) has proved unconvincingin the North American example. The possibility that atypicalmycobacteria should be implicated has been raised (Clark et al. 1987; Eisenberg 1986; Klepinger 1982) and will be dis-cussed in detail below.A novel approach, recently applied to the study of pre-historic tuberculosis, is the development of mathematicalmodels for the spread of disease. Although this strategy has alengthy history within the medical sciences (Grigg 1958;Waaler et al. 1962), it has been developed only recentlywithin paleoepidemiology (McGrath 1986,1988; Milner1980). As this form of investigation holds promise for estab-lishing expectations and comparabilities across time andspace, it also will be reviewed here. 161 162 Table 1. Recently reported cases of skeletal tuberculosis from North AmericaSue Localion Period Pathology Reference Moundville Tuberculosis in the Americas: Current perspectives ? 163 Modeling expectations for prehistory McGrath ( 1986, 1988) has developed a simulation approachto modeling expectations for the spread of tuberculosis with-in prehistoric communities. She chose as a basis for heranalyses a diachronic sequence of three paleopopulationsfrom west-central Illinois: Middle Woodland (150 b.c.-a.D.400). Late Woodland/Emergent Mississippian (a.d. 400-1050), and Mississippian (a.d. 1050- 1 150). This study areawas selected for its abundant archeological data, as well asthe fact that late prehistoric skeletal samples (Buikstra 1977;Buikstra and Cook 1 978 ,1981) show evidence of tuberculo- sis-like pathology. Estimates of regional population aggrega-tion and disease transmissibility are based upon currentarcheological wisdom concerning population size and settle-ment distributions. As emphasized by McGrath, the goal wasto demonstrate the value of simulation for paleoepidemio-logic study with the expectation that additional investigationsof regional prehistory will necessitate redefinition of basicparameters (McGrath 1986.1988).McGrath's stochastic adaptation of the Reed-Frost modelgenerates epidemic disease curves based upon specified as-sumptions concerning the behavior of tuberculosis in recenthuman groups. Communities were modeled either as small, stable units arranged linearly along the Illinois River (Middleand Late Woodland) or as scattered farmsteads (Mississip-pian). Regular interaction occurred between neighboringcommunities only, the Late Woodland contact pattern includ-ing more groups than the Middle Woodland example. Twice ayear Middle Woodland communities converged on a local "ceremonial center"; Mississippian groups traveled twice ayear to Cahokia, a large urban complex to the south.McGrath's estimated population parameters are presented inTable 2 (after McGrath 1988:489). Two levels of regionalpopulation numbers and settlement size are developed foreach model.McGrath's simulation tests the spread of tuberculosiswithin the hypothetical region over a 100-year period. Age-specific mortality rates are developed based on contemporaryexpectations for tuberculosis and a life table constructedfrom archeological data. Disease prevalence, the infectiousproportion of the population, and mortality patterning aremodeled. In all cases, with the exception of the second LateWoodland (LW2) model, the simulated populations experi-ence severe, drastic disease stress and become extinct withinthe 100-year period. In the LW2 example, the pathogen be-comes extinct. Again, with the exception of LW2, all groupsshow evidence of high disease prevalence? 100% for Mis-sissippian and 30-40% for the first Late Woodland and bothMiddle Woodland models.McGrath (1988:494) concludes that the key variable influ-encing the fate of these simulated populations is effectivepopulation size: TaBLL; 2. McCiralh's ( l'J88:489) population modelsRun Pop. Pop. Settle- Effeclnt-siz^ density ment pop. sizeMWl 164 ? Jane E. Buikstra and Sloan Williams 1958). We therefore may simply be documenting a flexiblehost-parasite relationship. An alternative suggestion is thepossibility that the prehistoric tuberculosis-like pathologydescribed in Illinois and elsewhere in the Americas wascau.sed by a pathogen other than M. tuberculosis (Buikstra1981; Clark et al. 1987; Eisenberg 1986; Klepinger 1982;McGrath 1986,1988). Atypical/environmental mycobacteria Recently, Clark and co-workers ( 1987) have underscored theimportance of considering mycobacteria other than M. tuber-culosis when assessing the impact and origins of thetuberculosis-like lesions of prehistoric tissues in the Amer-icas.What is known about the ecology of mycobacterial disease raises the possibilities that pre-Columbian "tuberculosis"was caused ( 1) by M. tuberculosis but in a population im-munized by exposure to environmental ("atypical") my-cobacteria; (2) by M. tuberculosis but a strain of low virulence; (3) by M. bovis transmitted by wild animals(e.g., butchering and tanning skins of infected bison), withinfection resulting in self-limiting disease and long-lastingimmunity; and/or (4) by one or more of the environmentalmycobacterial species. (Clark et al. 1987:51) In general , individuals who commented on this manuscriptcommended the authors for emphasizing the dynamic natureof host-parasite relationships. The possibility that the en-vironmental mycobacteria are heavily implicated in late pre-historic populations from the Americas is, however, ques-tioned. Katzenberg (1987:52) and Klepinger (1987:52), forinstance, emphasize that the prevalence of observedtuberculosis-iike pathology reported for late prehistoric pop- ulations in North America is consistent with an infectiousdisease spread by host-to-host transmission. The environ-mental pathogens are rarely, if ever, transferred between hu-mans (Lincoln and Gilbert 1972; Sommers 1979; Wolinsky1979).Steinbock (1987:56) points out that the calcified Ghoncomplexes reported by Allison and co-workers (1981) fortwo prehistoric and one colonial period South American re-mains are simply not consistent with disease caused by en-vironmental mycobacteria. Even though the environmentalmycobacteria could have produced the acid-fast reactionnoted by Allison and co-workers (1973), he considers thecalcified Ghon complex specific to tuberculosis.Kelley and Eisenberg have suggested that the skeletal le-sions produced by the environmental mycobacteria are "es-sentially identical" to those produced by M. tuberculosis(1987:94). A similar argument is offered by Clark et al.(1987:48-49). This generalization would appear, however,open to debate. In fact, the sources cited by Kelley and Eisen-berg in support of this statement are either silent (Good 1 980)or rather ambiguous concerning the form and distribution of skeletal lesions. Wolinsky (1974:645) notes that "severalcases of M. kansasii disease of the bones and joints are onrecord" but does not provide a comparison of the skeletallesions characteristic of tuberculosis and those caused by theenvironmental pathogens. In more recent work, Wolinsky(1979) reviews a number of cases of both disseminated andlocalized infections caused by the atypical mycobacteria. Inso doing, he emphasizes occupational trauma as a majorfactor influencing the distribution of skeletal lesions. Deephand infection is emphasized, with fewer cases reported forthe wrist, hip, knee, spine, and calcaneum. This review indi-cates that while the form taken by specific skeletal lesionsmay resemble tuberculosis, neither lesion location nor age-specific patterning mirrors that expected for tuberculosis(Wolinsky 1979).In fact, when case studies are reviewed, it appears thatboth age-specific patterning and intraindividual lesion dis-tributions for environmental mycobacterial infection diflerfrom tuberculosis (Ellis 1974; Halla et al. 1979; Halpem andNagel 1978; Lakhanpal et al. 1980). Vertebrae may be af-fected, but there is no convincing evidence of a tuberculosis-like predilection. Lakhanpal and co-workers, for instance,emphasize that the clinical, radiologic, and histologic ap-pearance of the lesions caused by M. kansasii is distinctivefrom that of tuberculosis. "It seems as if the basic pathologyof lesions caused by these organisms is different from the onecaused by Mycobacterium tuberculosis" (Lakhanpal et al.1980:473).Lincoln and Gilbert ( 1972:697) point out that "disease ofonly one area of the skeletal system was reported infre-quently" in their survey of children suffering from diseasecaused by acid-fast bacilli other than M. tuberculosis and M.bovis. They conclude that the disseminated mycobacteriosesattributed to the atypical forms most closely resemble a "ma-lignant type of reticuloendotheliosis" (Lincoln and Gilbert1972:708), not tuberculosis.For individual lesions, however, bony involvement in dis-ease caused by environmental mycobacteria could mimicexpectations for osseous tuberculosis (e.g., a 14-year-oldmale with lumbar vertebral and sacroiliac involvement; Ellis1974). Even so, it is difficult to disagree with Steinbock'scomment: "It is inconceivable that one of these forms |ofenvironmental mycobacteria] could be the pathogen for pre-Columbian tuberculosis" (1987:56).The geographic distribution and balanced gender ratiosobserved in North American prehistoric samples would alsoargue against acquisition through butchering or other occu-pations that would place an individual at risk for environmen-tal mycobacteria, as Clark et al. (1987) have argued. Thus,although it certainly is possible that these pathogens mayhave caused a few of the lesions reported in prehistoric seriesand they may likewise have influenced the expression ofdisease in certain individuals, it is unlikely that they can beseriously implicated in the vast majority of prehistoric exam-ples. Zagrrb Paleopathology Symp. 1988 Tuberculosis in the Americas: Current perspectives ? 165 The distribution and prevalence of the tuberculosis-likepathology recognized in the Americas during pre-Columbiantimes may, however, have been influenced by the environ-mental mycobacteria. In this light, it is instructive to note thatwhen the larger skeletal series represented in Table 1 areconsidered, relatively low population frequencies for tuber-culosis occur in the southeastern United States, at IreneMound and Moundville. Recent laboratory surveys of isolatedistribution and frequency for the nontuberculous mycobac-teria describe the Southeast as having high isolate fre-quencies for M. avium. M. fortuitum, M. kimsasii, and M.scrofulaceum (Falkinham et al. 1980; Good 1980; Good andSnider 1982). Inreaction to the Clark etal. (1987) argument,Powell has implicated cross-immunity due to the presence ofenvironmental mycobacteria to explain the "low visibility"of tuberculosis at Moundville (Powell 1988:180). Althoughincomplete archeological recovery may be cited in theMoundville example, the possibility that the distribution ofatypical mycobacteria may have influenced the prevalence ofprehistoric tuberculosis-like pathology should be consideredin studies of ancient disease in the New World.Clark et al. (1987) call attention to the presence of less virulent strains of tuberculosis that occur in India ("southIndian variant"), in other parts of south and southeast Asia,and in Africa. Such geographic variability underscores theflexibility of the pathogen-host relationship and is a topicworth considering further. It would be of interest, for in-stance , to discover the degree to which osseous lesions devel-op in these nonvirulent, pervasive forms. Certainly extensive skeletal involvement has been reported for victims of tuber-culosis in India (Ganguli 1963). It would also be appropriateto implement McGrath's simulation approach using variablesspecified according to the parameters common to the less virulent forms. North American model The recent case studies of the North American tuberculosis-like pathology reported in Table I expand the earlier sum-mary presented by Buikstra (1977:326). Although certainexamples fit expectations more tightly than others, it appearsthat there is now sound evidence for disease in eastern UnitedStates population centers such as the Cumberland Basin, thecentral Mississippi valley, and southern Ontario. Typical skeletal expressions of tuberculosis-like pathology are de-scribed in multiple individuals from several sites, includingNorris Farm #36, Schild Mississippian Cemetery, Mound- ville, Averbuch, and in the Ontario ossuaries reported byHartney (1981) and Pfeiffer (1984). With the exception ofan isolated lesion in a thoracic vertebra from the SerpentMounds (Anderson 1968), a single case from an Archaic shell mound (Rathbun et al. 1980), and an Illinois examplefrom uncertain context reported by Morse (1969:502) andOrtner and Putschar (1981:173), these skeletal series post-date A.D. 1000. Although uneven sex ratios occur in certain Zagreb Paleopathology Symp. 1988 contexts, both males and females, as well as all age groups, are represented. In the Schild and the Averbuch cases, the classic Pott's disease occurs in young adults. Healed cases,as at Irene Mound (Powell 1990), tend to be found in olderindividuals; disease active at the time of death is associatedwith juveniles and younger adults.Plains and the Southwest examples have increased in re-cent years. Although the sample size is small, they neverthe-less suggest a slightly earlier presence than in the easternexamples. Only one, however, cleariy predates a.d. lOCK):the Kayenta adolescent reported by Suinner (1985).The frequency data for the North American skeletal seriesis somewhat enigmatic when viewed from the perspective ofmodem clinical samples. When the larger, best preserved,and well-excavated series reported in Table 1 and in Buikstra(1977) are considered, percentage values range from theMoundville (5.2%), Irene Mound (5.7%) and Schild Ceme-tery (6.7%) figures to 12.1% for the Norris Farm #36 site.(The Averbuch frequency may also be as high as 6. 1%, butthis is difficult to interpret since Kelley and Eisenberg (1987)apparently include individuals with periosteal remodeling inlong bones in the absence of other pathognomic lesions. ) The oft-cited figures of 5-7% bony involvement in modem hos-pital samples (Steinbock 1976:175,1987:55), even temperedby Kelley and Micozzi's (1984) observations in the Hamann-Todd collection, suggest that virtually every member of theselate prehistoric communities had primary exposure to tuber- culosis, as suggested by Klepinger ( 1987:52). In situations ofextreme social and biological stress, such as that reported byMilner et al. (1988) for the Norris Fami #36 population,prevalence of chronic destructive disease appears to havebeen extreme. South America Allison and co-workers (1973; 1981) have reported a seriesof 12 remains from Peru and Chile that they consider to beexpressions of tuberculosis. Of these, three (1981, cases 4,5and 9) could be postcontact. The diagnosis of the cranialgranuloma in case 1 1 (Allison et al. 1981:51) is sufficientlyproblematic that it will also be excluded from discussionhere. Of the remaining eight prehistoric examples, four show skeletal involvement, three without confirming soft tissuepathology. The remaining four are diagnosed based uponhealed Ghon complexes (cases 2 and 8) and cavitary pulmo-nary disease in association with acid-fast bacilli (cases 6and 7).The examples with skeletal involvement include one juve- nile 8- 10 years of age. two males: one listed as 4 1 -H years ofage and another "adult," and an isolated female 40 years old.Those diagnosed through soft tissue include the 8-IO-year-old juvenile with Pott's disease, a 14-year-old female, a male adult, and two females: 50 and 56+ years old. Thus, thereare two juveniles and four middle-old adults. Individualsdying within the young adult years are conspicuously absent 166 ? Jane E. Buikstra and Sloan Williams Table 3. Age distributions for tubercular and nontubercularremains from the Estuquina site Table 4. Age distributions for tubercular and nontubercular remainsfrom the Estuquina site Age range Tuberculosis in the Americas: Current perspectives ? 167 reported, as arc abscesses on the external aspect of the thorax(Hodgson et al. 1969; Yau and Hodgson 1968; Jaffe 1972;Johnson and Rothstein 19.'S2; Rechtman 1929),Most clinical experience with rib tuberculosis follows thepattern described by Tatelman and Drouillard ( 1953). Theseauthors report four types of tuberculosis of the rib: ( 1 ) cos-tovertebral. (2) costochondral, (3) isolated body lesion, and(4) multiple cystic foci. In each case, destructive processesconstitute the primary symptom, with the majority of thelesions involving the body. These resorptive foci follow thetypical pattern for bone tuberculosis and are clearly dilTcrentfrom the mild periostitic response described by Kelley andMicozzi ( 1984). Certainly, the features described by Kelleyand Micozzi may indeed reflect tuberculosis. Persons en-gaged in paleoepidemiological study should, however, alsobe aware of the patterns typically taken by the resorptive foci reptirted in the medical literature.Although Kelley and Micozzi (1984:386) correctly indi-cate that tuberculosis is the most commonly observed inflam-matory condition in the ribs, a differential diagnosis of riblesions attributable to tuberculosis must consider other formsof pathology. For instance, Tatelman and Drouillard reportthat "tuberculosis is second only to metastatic malignancy as a cause of destructive lesions of the ribs" (1953:923). Thus, itis clear that metastatic processes must be considered in devel-oping a differential diagnosis of tuberculosis-like lesions in ribs.In discussing differential diagnosis, Kelley and Micozzi(1984:386) state: "Conditions to be considered in the differ- ential diagnosis of skeletal tuberculosis are actinomycosis,typhoid, pyogenic osteomyelitis and syphilis (Sinoff and Se-gal 1975)." Sinoff and Segal's article, entitled "Tuberculousosteomyelitis of the ribs: a case report," however, makes itclear that their primary concern is with manifestations in the rib. rather than "skeletal tuberculosis" in general, as sug-gested by Kelley and Micozzi. The full quotation from Sinoffand Segal reads: "The single most important differential di-agnosis (in rib tuberculosis) is metastatic carcinoma, butother possible diseases include: (i) actinomycosis, (ii) ty-phoid or paratyphoid osteomyelitis, (iii) pyogenic os-teomyelitis and (iv) syphilis" (1975:866). Thus. Sinoff andSegal are focusing upon tuberculous manifestations of the riband emphasizing metastatic carcinoma.Kelley and Micozzi (1984:386) follow their listing of dis-eases appropriate for differential diagnosis in "skeletaltuberculosis"?actinomycosis, typhoid, pyogenic osteo- myelitis, and syphilis?with the statement. "However, noneof these conditions commonly affects the ribs." This conclu-sion is remarkable since Sinoff and Segal (1975) are clearlyconcentrating upon forms of disease affecting the rih. And infact, one of the conditions most likely to produce just the typeof proliferative response described by Kelley and Micozzi isactinomycosis. Tatelman and Drouilard (1953:932) describe rib involvement in actinomycosis through direct extensionfrom lung and pleural involvement, emphasizing productive2agnb Paleopathology Symp 1988 changes due to this condition. A classic description derivesfrom Edeiken (1981:792): "When the thoracic wall is af-fected, the ribs may show destruction, although they usually react with periosteal new bone formation and become thick . . . which, although not diagnostic of actinomycosis, ismost suggestive." Clearly, actinomycosis and perhaps other related disease processes must be considered when periostiticreaction is observed on ancient ribs. Thus, while Kelley andMicozzi may be correct in attributing the mild periostitisobserved in the Hamann-Todd series to tuberculosis, it isclear that conditions other than tuberculosis can produceperiosteal reaction on ribs.The age profiles for the total Estuquina skeletal series andthe subsample with more than five observable thoracic/lum-bar vertebrae (Table 3) do not differ significantly (Kolmo-gorov-Smimov test, D? ? = 0.06; D^^, = 0.1 1 1; p > .05).For the purposes of further testing, the affected individualsare compared with the vertebrally observable subsample.The two subgroups, rib and nonrib. indicated in Table 4 donot differ significantly in age structure (D^, ? = 92; D^^,^ =142; p > .05). The total affected sample does, however,differ significantly in mortality experience from the largerEstuquina skeletal series (D,? ? = 0.33; D^.?, = 0.29; p < .01). This difference is influenced primarily by the elevatednumbers of affected individuals in the young adult and el-derly adult years. The former include active cases, while thelatter comprise the more extreme and healed examples. Low visibility and perhaps low prevalence of bony involvementlikely affect the figures for young juveniles.These results indicate that young adults are overrepre-sented in the affected sample, as they were not in the seriesreported by Allison et al. (1981). This apparent elevation ofyoung adult morbidity, whether the full series or only thatwith more than five thoracic or lumbar vertebrae present isused for comparison, is expected for a tuberculosis-likepathology. The pattern is characteristic of the larger NorthAmerican samples reported in Table 1 . An unusual feature of the Estuquina series is, however, anapparent skewed sex ratio. Although males are overrepre-sented in the full sample (99 males, 71 females), the affectedadult sample presents a decidedly more extreme bias (19males, 7 females). When the tubercular sample is subdividedby area of involvement (Table 4), we find rib lesions in 8males and 4 females, while among the remainder, 12 malesand only 3 females are affected. Two of the three femaleswith classic Pott's disease are older individuals with extremedegeneration of the spine (M6-102la, M6-5390). A chi-square compari.son indicates that sex ratio of affected individ- uals is significantly different from the total sample (x^ =4.346, p = .037). Partitioning the affected group by lesionlocation demonstrates that the individuals presenting rib in-volvement are not so biased toward males as those presentingclassic Pott's disease. The comparison for those with riblesions yields a X' of 0.377 (p = .539). The value for themore "classic" examples is 3.204 (p < .073). 168 ? Jane E. Buikstra and Sloan WilliamsSummary and conclusions Recent years have seen several new and productive ap-proaches to issues relating to the tuberculosis-like pathologypresent among prehistoric human remains in the Americas.The simulation modeling developed by McGrath suggeststhat a pathogen behaving much like modem M. tuberculosiscould not have been maintained within certain North Ameri-can prehistoric groups. In the face of skeletal evidence docu-menting the presence of the disease in west-central Illinois,we must consider the possibility that the pathogen responsi-ble was not M. tuberculosis and that we are documenting ahost pathogen relationship not common in recent history. Inthis case, McGrath's model based upon disease experience inmodem human groups would have been misspecified.Clark et al. (1987) have postulated an important role forthe "environmental mycobacteria" in explaining the expres-sion of apparent tubercular disease. While we agree that inisolated cases, the possibility that skeletal lesions resultingfrom the atypical mycobacteria may mimic those caused byM. tuberculosis, it is unlikely that the environmental patho-gens were responsible for many of the tuberculosis-like le-sions described for late prehistoric series. Certainly, as atMoundville, it is possible that disease prevalence was influ-enced by the presence of environmental mycobacteria. Fur-ther investigations of geographic distributions for the my-cobacteria and prevalence figures for ancient disease may,therefore, prove instructive.Finally, we have described patteming for a tuberculosis-like pathology in a large series of skeletons from southemPeru. Although prior studies of Andean remains had de-scribed an age-specific lesion pattern different from that re-ported in North America, the Estuquina site series showsstrong similarity to their northern contemporaries. Thestrong sex bias in the sample, however, remains problematic.In closing we would like to take issue with Clark et al.'s(1987:58) assertion that "from the anthropological perspec-tive, differential diagnosis is unproductive, at least whenadaptation and evolution are the primary foci." We mustengage in differential diagnosis, if we are to represent fullyand accurately the health status of prior human groups. Oth- erwi.se we risk confusing the degenerative results of occupa-tional stress with the products of trauma, the treponematoseswith fungal infections, the presence of widespread, epidemicdisease with the impact of environmental pathogens, and theimpact of nutritional imbalance with the results of infectiousprocesses. Without concern for differentiating disease forms,we will at best obfuscate and at worst misrepresent the courseof human history. Differential diagnosis is no more an emptyexercise than theorizing without considering contradictoryempirical evidence. The study of human adaptation in thepast requires scientific methodology, including both theoryand data-based tests. As illustrated by the current controver- sies surrounding prehistoric "tuberculosis" in the Americas,differential diagnosis plays a crucial role in this process. Acknowledgments The research reported here was funded by the National Sci-ence Foundation (BNS87- 17590), the Center for Latin Amer-ican Studies, and the Lichtstem Fund of the AnthropologyDepartment at the University of Chicago. The content andorganization of the document has benefited immeasurablyfrom the criticism of Mary Powell and Lisa Leuschner. Appendix. Individuals with tuberculosis-like pathologyfrom Estuquina site M6-I8I : Sex unknown, 25-30 years. ResorpU\e areas on intemalaspect of ribs. M6-336a: Male 39+ years. At time of death remodeling was activein lumbar region. LI only slightly affected, with resorption oninferior and lateral aspects of body. Much of this area does not show sclerotic emargination . Superior aspect of L4 has a ca. 5-mm cavita-tion with sclerotic emargination that appears to have recently "broken through" to surface. Disk spaces in lumbar region and atL5-S1 have been crossed by process. Anterior aspect of L2-S1bodies also present periosteal proliferation. M6-771 : Child 2-3.25 years. Slight amount of light, pinpoint cribra orbitalia is observable. Porotic hyperostosis appears on oc- cipital, near lambdoid suture. All deciduous teeth show dark stain-ing on buccal aspect near CEJ. Linear enamel hypoplasia present in all incisors.Limb long bones show porosity, especially at metaphyses. as wellas remodeling in areas of tendon/ligament attachment. Both iliapresent unusual porosity on external surfaces. Sternum very porous,especially the manubrium.Ribs show sclerotic raised areas on intemal aspect of bodies of right ribs 9-12, esp. 1 1 . It is this pathology that has drawn M6-77 1 into the affected group, along with periosteal remodeling on exter- nal aspects of ilia. Remodeling of limb long bones is subtle, notfulminating onion-skin expansion noted in others from the Estu-quina sample.Well-integrated remodeled diaphyseal bone and dental pigmenta-tion suggest long-standing health problems for this individual. M6-I002: Male 17- 19 years. 7th thoracic unit shows a multilocularresorptive area, without much obvious sclerotic emargination. M6-I02la: Female 45 + . Right scapula and humerus have con-figuration that could be the result of a tubercular prcK-ess. If so,onset occurred before individual was fully (skeletally) mature sincethe disease seems to have caused resorption and dislocation ofhumems head, which is fused to glenoid fossa of scapula. Glenoidfossa surrounding this area shows focal lesions ca. 5-7 mm indiameter, with sclerotic emargination.Spinal column heavily involved. There is an oval cavity on C6,1.1 X 0.5 cm in diameter, into which C5 fits. Epiphyseal ring ofC6has formed a buttressing osteophyte, again suggesting long-termpathology. This strut was sufficiently efficient that there was littleapparent loss of effective body height.T3; superior surface of body has collapsed into an intemal lesion,which displays sclerotic emargination. Zagreb Paleopathology Symp. 1988 Tuberculosis in the Americas: Current perspectives ? 169 T4 shows a small focal resorption on right side of body, withepiphyseal ring gone. Body height loss, leading to scoliosis, appar- ent.T5/T6: circumferential porosity and remodeling on both bodies.T7: erosive circumferential lesions, mostly small (ca. 2-3 mm)foci. Slightly larger resorptive areas occur within neural canal,extending onto pedicles. This is the only pedicle involvement ob-served in M6-102la.T8 shows a central lesion with the main opening inferiorly di- rected, although a superior perforation also occurs. Multilocular sclerotic cmargination.T9-T10 fused through bodies only, with disk space gone. Ero-sive circumferential remodeling on each body.Til: circumferential erosion present with one resorptive focus atmidline.TI2 relatively intact.L1-L4 ankylosed kyphosed mass, fused through neural arches.Body of L3 entirely gone, with a few residual osteophytes. A lesionwas observed in bixiy of LI , in addition to circumferential erosionunder anterior longitudinal ligament. L1-L2 fused through arch only, as are L3-L4. L4 has massive erosive area under anteriorlongitudinal ligament.L5 fused to sacrum. Extensive zygapophysial arthritis is probablya secondary result of disease process. M6-1025: 5.5-7.5 months. Main involvement is in right hip. Ero-sion of acetabulum with onion-skin proliferation extending over allof internal and external surfaces. Right femur shows heavy re-modeling in area of greater trochanter that extends to linea aspera.Unfortunately, this region is poorly preserved. M6-1 183a: Male 35-39 years. L5 and SI are affected. L5 showsevidence of an active disease process eroding inferior surface ofbody. Sclerotic reaction clearly present, with bony reactive pro-cesses active at time of death. Trabeeulae coarsened. Neural arches,i.e., zygapophysis, affected by osteoarthritic change secondary todisease. SI presents a complementary lesion pattern. M6-1 183b: Male 50+ . Remodeling observed on interhal aspects of ribs. Surface well integrated: costal groove obliterated. M6-I2I5: 12-15 years. Remodeling evident at sternal ends of ribs. M6-I223: 5-7 months. An infant with fiberbone periostitis begin-ning to develop on internal aspects of both ilia, r > I. Long bonesshow evidence of periosteal remodeling. Both internal and externalsurfaces of cranial vault are slightly porous. M6-1557: Sex unknown, adult. Periostitis observed on internal as-pect of ribs. M6-l6IOa: Male 45-50 years. Periostitis observed on internal as-pect of ribs.M6- 1616a: Male 35-45 years. Internal surface of ribs shows evi-dence of integrated periosteal reaction.M6-2256a: Male 30-40 years. 9th and 10th thoracic elements areaffected. This may be an ostcomyclitic process since no other vcrtebrae are affected, but will include it as a possible example oftuberculosis. Zagreb Paleopathology Symp. 1988 T9: much of body destroyed by disease process. Superficial newbone formation is present. Only approximately 2/3 of superior sur-face is intact, as is right side. Superficial remodeling present onexternal aspect of vertebral body. Sclerotic reaction of trabeeulaebone has smoothed interior "surface," although two oval reactionarea remnants remain.TIO: body height maintained on left side. Sclerotic emarginationof oval lesions evident in body.Kyphosis due to complementary destruction of these two ver-tebrae could have led to an acute angulation of as much as 30?. M6-2279b: Male 20-21 years. L5 (only lumbar vertebra fully ob-servable) shows extensive remodeling on superior surface of bodyand multiloculated lesions. Body height reduced. Lesions extendinto pedicles. Other lumbar fragments suggest no additional unitsaffected. M6-2297a: Male 27-30 years. Involvement ofT9-T1 1 which pres-ent multiloculated erosive areas. No loss of vertebral body height,no arch involvement. Destructive foci extending across disk spaceapparent at levels of T9-TI0, TIO-Tl I . Sclerotic cmargination ofresorptive regions is characteristic. M6-2330: 1-2 years. Inferior surfaces of centra of two lumbarvertebrae present extensive remodeling and multiple small,coalesced resorptive areas. In addition, sternal extremity of threeleft ribs present expansive periosteal remodeling. M6-3l98a: Male 20-21 years. L5 (only lumbar vertebra fully ob-servable) shows extensive remodeling on superior surface of body.Multiloculated lesions apparent, and extend into pedicles. Bodyheight diminished. Other lumbar fragments suggest no additional units affected.M6-3205: Male 27-30 years. Periostitis observed in internal aspectof ribs.M6-3215: Male 25-30 years. Heavily remodeled spinal columnand lower portion of body. Long bones porous , with some periosteal reaction. Weight-bearing joint surfaces somewhat porous. Tarsals ingeneral are light in weight, and appear expanded and porous. Meta-tarsal bodies show periostitic reaction. Auricular surface of rightinnominate heavily eroded, with some sclerotic emargination.Remnants of oval lesions evident.Circumferential remodeling evident on T3-TI 1 . T4 shows someporosity that may be post mortem. Part of inferior body has col-lapsed into internal lesion. Sclerotic emargination is obvious.T7: anterior portion of body eroded and absent.T8: left side of body eroded and absent. Focal lesions evident, asis sclerotic emargination.T9: 1.8 X 1 .3 cm resorptive space present on right side of body.This feature leads into internal, smaller focal resorption. Body hascollapsed with little proliferative reaction.Ribs: at least three left and five right show expansion on internalaspect of neck. Proliferative reaction has added up to 2 mm of newbone. Both sclerotic and active fiberbone reaction is evident frommid to lower thorax. These bodies are expanded internally such thaicostal grooves are indistinct. M6-324Ha: Female 25-26 years. Evidence of remodeled perio,stitison internal aspect of ribs. 170 ? Jane E. Buikstra and Sloan Williams M6-3269a: Sex unknown, adult.internal aspect of manubrium. Periosteal reaction obvious on M6-3299: Male 18-19 years. Periostitis observed on internal aspectof ribs and on anterior surface of L3. M6-3644a: Female 25-26 years. Remains were recovered from a collar tomb that contained a minimum number of five individuals,including three adults. Two adjacent (T9/TI0) lower thoracic ver-tebrae exhibit massive resorptive lesions within the bodies. On sufx;rior surt'ace of T9, three coalesced large foci arc visible. Bodyheight maintained on right side, but destroyed on left. Only anteriorand right side of TIO body present, showing circumferential boneproliferation. Erosive lesions have destroyed interior portion ofbody. Inferior aspect had apparently fused to Tl I (not recovered).Right postzygapophysis and inferior surface of a 2d or 3d lumbarvertebra from this set of commingled remains also show extensive resorption. M6-4I65: Male 27-30 years. Solitary lesion apparent on left side ofL4 body, ca. 2 cm in diameter, that perforates to left side. Modestamount of proliferative bone around lesions. Osteophytes extend toL3. L3 not affected. M6-4176: Male 22-24 years. Right sacroiliac articulation heavilyeroded by disease process, which is somewhat obscured by post-mortem change. A lesion on articular surface has penetrated exter- nal surface. Periosteal reaction evident on opposite external face.Reaction evident on proximal portion of right femoral diaphysis. M6-42l3a: Female 50+ years. Ribs present internal expansion ofbone well integrated at time of death. No costal groove observable. M6-4256: Male 45+ years. TIO-TI 1 affected by erosive processthat has produced extensive loss of body height on inferior aspect ofTIO and superior aspect of Tl I. A kyphosis of ca. 30? was pro-duced. Sclerotic emargination evident on all lesions. Pedicles af-fected on both vertebrae.At least five left and two right ribs show periosteal reaction ontheir vertebral aspects, extending across bodies past angles. Costalgrooves obscured. In that these are lower ribs, the reaction is proba-bly related to degenerative process observed in vertebrae. M6-4268: Female 22-24 years. Periostitis observed on internalaspect of ribs. M6-5390: Female 50+ years. This individual shows characteristicand extensive skeletal changes.Right ilium ankylosed to sacrum.Vertebral involvement extensive. Initial focus of disease processwas In bodies of T10-TI2, with subsequent extension to LI-T9.kyphosis (ca. 90?) and ankylosis. Lesions occur adjacent to disks inL5 and T9-TI2. L2, T3, T4. T5, and T6 present oval resorptiveareas posterioriy, adjacent to foramina for basivertebral veins. Cir-cumferential resorption occurs in T3-T8 and L3. The most exten-sive neural arch involvement Is in L2. with pedicles affected In T4-T7, T9-T12, and L3. Transverse processes show pathological re-sorptive areas In TS-T?. Bones of feet somewhat porous, with notable periostitis on lateralaspect of calcancl. There are two sets of fused foot phalanges.Most ribs, nine left, eight right, have arthritic articular facets inaddition to periostitis located on their necks. Most Inferior ribs areremodeled externally. M6-5428: Male 50+ years. Healed periosteal reaction evident oninternal aspect of ribs. M6-5838a: Female 50+ years. Periostitis on internal surface of rib. M6-5859: Male 35+ years. Periostitis noted on Intemal aspects of ribs. M6-6464: Male 35-39 years. LI and L3 both have resorptive le- sions, with anterior surface of L3 and posterior surface of LI being affected. Right acetabulum and caput femoris present trabecularexposure following premortem cortical resorption. Left scapulaalso has a large channel extended vertically through glenoid fossa. M6-82 lOa: Se.x unknown, middle-old adult. Healed periosteal reac-tion on Intemal aspect of ribs. M6-9334: Male 39-44 years. Small resorptive area on superiorsurface of rib. M6-99407b: 2.5-3.0 years. Ribs expanded, as are long bones andilia. Involvement of ribs emphasized. Literature cited Allison, M.J. 1984. Paleopathology In Peruvian and Chilean Popu-lations. In M.N. Cohen and G.J. Armelagos. eds.. 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Some pointed out that disease rates did not always correlatewith population size, such as the high rate of tuberculosis in thesmall Bedouin groups. It was noted, however, that the author wasidentifying the larger population size with which certain smaller,more isolated groups came into contact during their periodic rituals. Zagreb Paleopathology Symp. 1988 Endemic treponematosis and tuberculosisin the prehistoric southeastern United States:Biological costs of chronic endemic disease Mary Lucas Powell 1 he importance of infectious disease as a selective force inhuman adaptation has been argued eloquently during the pastquarter century (Alland 1970; Armelagos et al. 1978;Buikstra 1981; Buikstra and Cook 1980; Burnet and White1972; Cockbum 1973; McNeal 1976; Ortner and Putschar1981). Many recent assessments of health in prehistoric pop-ulations have treated only in general terms the observed prev-alence of nonspecific periostitis, osteitis, and osteomyelitis,with little or no consideration of specific infectious diseases.The most commonly reported nonspecific lesion, periostitis,may represent illness caused by endogenous bacterial and viral infections, certain endemic (and more rarely, epidemic)infectious diseases, nutritional disorders, trauma, or a vari-ety of congenital syndromes (Greenfield 1980; Jaffe 1972). Its mere presence in an individual or a population reportedwithout an epidemiological context is of minor significancein evaluation of the biological costs of infectious diseaseexperience.Differential diagnosis of specific infectious diseases re-quires familiarity with the pathogenesis and epidemiology ofthe diseases in question. Certain infectious diseases such astreponematosis and tuberculosis produce both pathog-nomonic skeletal pathology (e.g., caries sicca in the former,extensive vertebral destruction in the latter) and nonspecificresponse. Ortner and Putschar (1981:105) note that "infec-tious conditions affecting the skeleton tend to be subacute,chronic diseases and may not be the immediate cause ofdeath." Because bone lesions typically occur relatively latein the progress of disease subsequent to considerable softtissue involvement, their presence is indicative of relativelylong-term immune response. Some chronic diseases typ-ically produce abundant skeletal morbidity yet rarely result indeath, because of the nature of their pathophysiological effects, while others may produce high mortality but fewcases of skeletal involvement (Hackett 1951; Robbins andCotran 1980). This paperoutlinesbriefiy the different biolog-ical costs of two chronic infectious di.seascs with distinctive-ly different patterns of skeletal involvement and mortal im-iagrtb Paleopathology Symp. 1988 pact, endemic treponematosis and tuberculosis, that havebeen recently identified in skeletal samples from lateprehistoric American Indian populations in Alabama andGeorgia. Endemic treponematosis and tuberculosis Yaws, endemic syphilis, and venereal syphilis are consideredto be closely related disease entities because of the similarityof their causal organisms and the morphology of their lesionsof skin and bone (Grin 1953; Hackett 1976; Hudson 1958;Turner and Hollander 1957). As regards levels of morbidityand mortality, however, the first two are radically differentfrom their more dangerous relative, being both more widelyprevalent and more benign because of their mode of trans-mission and their pathophysiological effects. They are typ-ically contracted in early childhood through direct contactwith infectious skin lesions rather than through venerealtransmission. Prevalence levels in endemic regions approach100%, and lesions occur in approximately 50% to 75% oflate secondary and tertiary cases, resulting from hyper-allergic response to superinfection by the sensitized hosts(Hackett 1951). Both congenital transmission and invasionof vital organ systems are rare, in contrast to the well-documented effects of venereal syphilis (Grin 1956; Murray et al. 1956). These diseases do not noticeably dampen fertil-ity, and exert a negligible impact upon mortality except indi- rectly through secondary bacterial or mycotic infection ofskin lesions.In his comprehensive study of endemic yaws in Uganda ( I95I ), C.J. Hackett sought to document the complete rangeof bone lesions observed radiographically in patients diag-nosed by serological analysis. He noted in his introduction, "It is not the differential diagnosis of the changes present inone patient, but of those ... in a whole population that isbeing considered." Hackett found that while some patientsdisplayed "classic" bone lesions characteristic of late second-ary and tertiary yaws (sabre shins, polydactylitis, and os-173 174 ? Mary Lucas Powell Table 1. Tuberculosis and endemic treponematosis: comparison of morbid and mortal effects Pathogen Mode of infectionModal age at exposureModal age at onsetof diseaseDuration of infectious state of patient Initial lesionsSubsequent lesionsPrevalence of diseasein endemic contextsPrevalence of skeletalinvolvementPredominant skeletalresponseSkeletal regionstypically affected Potential for mortal effect Tuberculosis Treponematosis EPIDEMIOLOGYMycobacteriumtuberculosisRespiration, ingestionChildhoodLate adolescence, early adulthoodDecades (withlatent periods) Treponema pallidum, T. pertenueSkin lesionsChildhoodChildhood 5-10 years PATHOLOGY Lungs, hilar lymph nodesAny organ system10-50% of exposedindividuals3 - 15% of cases Major: osteolyticMinor: osteoblasticSpinal column,hip and knee joints, ribs, sternum Moderate to high Mucocutaneous tissuesMucocutaneous tissue, boneVirtually 100% of exposedindividuals50-75% of cases Major: osteoblasticMinor: osteolyticTibia, fibula, humerus, radius, ulna, clavicle, cranial vault, nasopalatal regionLow Sources: Hackett 1951, Hoeprich 1977, Hudson 1958, Kelley and Micozzi 1984, Myers 1951,Ortner and Putschar 1981, Robbins and Cotran 1980 teolytic lesions of the external cranial vault and nasopalatal region), many more exhibited minor nonspecific bone reac-tions (periostitis of long bone shafts, particularly the tibia,fibula, ulna, radius and clavicle). Subsequent radiographicexamination of these patients indicated long-term persistenceof bone changes after the disappearance of the clinical symp-toms.Commenting upon the high level of moderate skeletal mor-bidity without associated mortality, Hackett concluded that "it is improbable that septic infection of the bones is responsi-ble for the changes seen. Untreated septic infection of theextent necessary to produce the wide spread changes seen insome cases would be accompanied by grave general symp-toms and high mortality; whereas the patients showing thesebone lesions were not severely ill. although they sufferedconsiderable discomfort" ( 1 95 1 : 1 3). Studies of yaws in otherpopulations (Grin 1956) and of endemic syphilis in Bosnia(Grin 1953) and in southern Africa (Murray et al. 1956)present similar pictures of the biological costs of these dis-eases. Zagreb Paleopathology Symp. 1988 Tuberculosis is a chronic infectious disease caused by thegram-negative Mycobacterium tuberculosis. Clinical studiesindicate that in endemic contexts, most people are infected ininfancy or childhood, but more than half of the exposed butotherwise healthy individuals may never develop clinical dis-ease (Myers 195 1 ). Individuals with poor immune responsemay develop primary lesions within the lungs and hilarlymph nodes. If death does not ensue during the primaryinfection, the invading pathogens may be encapsulated by calcified tissue. This response halts immediate progressionof the disease, but the organisms remain viable for decades(Robbins and Cotran 1980). Localized foci may rupture andspread mycobactena via direct or hematogenous dissemina-tion throughout the body, affecting all types of tissue includ-ing bone. Reinfection from active cases or reactivation oflatent foci because of severe systemic stress may produceacute symptoms later in life (Hoeprich 1977).In chronic tuberculosis overstimulation of immune re-sponses in sensitized tissues may result in such proliferationof granulomatous tissue within the lungs that pulmonary Treponematosis and tuberculosis in tiie prehistoric southeastern United States ? 175 function is compromised and death follows. Tuberculosiswas a major cause of death in children, adolescents andyoung adults before the development of effective surgicaland antibiotic therapy and was responsible for 260 deaths per100,000 residents in Germany in 1892 (Ortner and Putschar 1 98 1 : 1 42 ). Mortality from tuberculosis is particularly high inpopulations under severe stress from malnutrition, over-crowded and unsanitary living conditions, other diseases,and psychosocial stress (Hrdlicka 1909; Hoeprich 1977; My- ers 195 1 ). Under more healthful conditions, successful repairof tissue destruction permits extended survival of the host, anoutcome incidentally in the pathogen's favor as it promotessubsequent infection of other hosts.Table 1 summarizes the contrasting morbid and mortal effects of endemic treponematosis and tuberculosis. Thesediffering patterns have important implications for paleo-pathological studies of the two diseases, for the followingreasons. Tuberculosis is less "visible" than endemic trep-onematosis in skeletal series. In older museum collections,spinal elements tend to be less well represented than longbones because vertebrae are more prone to postmortem de-struction and because in many field situations they were lesssystematically collected. In the Moundville series, for exam-ple, fewer than 407c of the individuals were represented bythoracic and/or lumbar vertebrae, the most common sites oftubercular bone lesions. By contrast, more than 70% wererepresented by the postcranial bones most characteristicallyaffected by treponemal infection.The nature of the lesions produced by the different diseasesalso plays a role in affecting favorably or unfavorably thechances for postmortem preservation. The osteolytic lesions characteristic of tuberculosis destroy bone tissue and weakenthe fabric of affected skeletal elements. The osteoblastic le-sions characteristic of endemic treponematosis produce addi-tional bone, thickening the cortex of affected long bones andrendering them more resistant to dissolution. Materials and methods The first population sample discussed in this paper was exca-vated from the prehistoric American Indian community ofMoundville located on the Black Warrior River some 13miles southeast of Tuscaloosa in west central Alabama. Itrepresents the Mississippian occupation of the site, whichlasted from A. D. 1050 to 1550. By the mid- 14th century, anestimated 3000 individuals were concentrated within the pro-tective palisade and in small "suburban" clusters located nearby. The subtropical climate and the easily cultivated,fertile soils encouraged the development of a sophisticatedsubsistence regimen combining maize, squash, and beanswith a wide variety of plentiful wild plant foods, game, andfish (Peebles 1978).More than 1500 burials were excavated at Moundvillebetween 1929 and 1941 by the Alabama State Museum ofNatural History, and are presently curated at the Laboratory Zagreb Paleopathology Symp. 1988 for Human Osteology at the University of Alabama inTuscaloosa. From this large series, 564 skeletal individualswere selected on the basis of preservation and archeologicalprovenience for investigation of the social and biologicaldimensions of health (Powell 1988).The second population sample represents a late prehistoriccommunity at the Irene Mound site, located near the mouthof the Savannah River on the Atlantic coast. This occupationwas contemporaneous with Moundville, spanning three cen-turies (a. D. 1 1 10- 1400) during the Savannah and early Irenephases of the local Mississippian cultural tradition. Sub-sistence and other aspects of life in this smaller communitywere similar to those noted for Moundville. Continuous ar-cheological excavations at the site from 1939 to 1940 sup-ported by federal relief funds recovered 265 skeletal individ- uals, presently curated at the National Museum of NaturalHistory, Smithsonian Institution, in Washington. D.C. Thedata reported here were collected as part of a general assess-ment of health at Irene Mound (Powell 1990).For each series, all available bones were examined formacroscopic evidence of skeletal pathology. Observed le-sions were classified as osteoblastic or osteolytic in morphol-ogy, as active or quiescent at the time of death, and accordingto their extent of involvement. The differential diagnoses oftreponematosis and tuberculosis were based on identificationof pathognomonic lesions and comparisons of the patterns ofassociated nonspecific skeletal pathology (Figure 1). VenerealSyphilis Endemic Syphilis Yaws IvloundvilleTreponematosis Figure 1. Distribution of skeletal lesions in four treponemalsyndromes. Solid shaded areas are those most frequently affected; hatched areas are less often involved. Figures show-ing syphilis and yaws after Steinbock 1976. 176 ? Mary Lucas Powell Figure 2. Irene Mound, NMNH 385528,treponematosis, sabre shins (shown with non-pathological tibia, center, for comparison). Figure 3. Moundville, tibia. ResultsA diagnosis of endemic treponematosis was initially sug-gested in both series by the frequent appearance of localizedor extensive periostitis on the shafts of the tibia, fibula, ra-dius and ulna. The thickness and degree of remodeling of thisnew bone suggested the recurrent episodes of periosteal in-flammation described by Hackett (195 i) during the late sec-ondary and tertiary stages of yaws. Many tibiae display areasof localized apposition along the anterior crest, a region sub-ject to the frequent minor trauma noted by Hackett as anexacerbating factor in soft tissue lesion formation. Othersshow more severe extensive pathological involvement, illus-trated by cases from Irene Mound (Figure 2) and Moundville(Figure 3) that resemble the deformity known in modemtreponematosis as "sabre shins." Md 1394 Figure 4. Moundville, cranial lesions. Treponematosis and tuberculosis in the prehistoric southeastern United States ? 177 Figure 6. Moundvilie. posterior cranial vault, stellate le-sions. Figure 7. Irene Mound, NMNH 385540, treponematosis,right nasal margin remodeling. young adult female from Irene Mound (Figure 7), who alsodisplays remodeled frontal lesions. The right border of hernasal aperture shows extensive remodeling. Destruction offacial structures of this sort is known as "gangosa," a Spanishword referring to the harsh nasal quality of the victim's voice(Hudson 1958). Because of their pre-Columbian prove-nience, no historical descriptions of the Moundvilie or IreneMound populations exist. However, in 1709 the EnglishmanJohn Lawson described ailments that resemble endemic trep-onematosis among the Santee Indians some 200 miles to thenorth of Irene Mound. He wrote, ". . . they have a sort ofRheumatism or Burning of the Limbs, which tortures themgrievously, at which times their legs are so hot, that theyemploy the young People continually to pour water downthem" (1709:223). Lawson also noted "another Distemper,which is, in some respects, like the Pox, but is attended withno Gonorrhea. This not seldom bereaves them of theirNose." (1709:223). The Santee made a clear distinction be-tween pre-Contact and post-Contact diseases, leading Law-son to comment "... the Natives of America have for manyAges (by their own Confession) been afflicted with a Dis-temper much like the Lues Venerea which hath all the Symp-tions of the Pox, being different in this only: for 1 never couldlearn, that this Country-Distemper, or Yawes, is begun orcontinued with a Gonorrhea. ... I have known mercurialUnguents and remedies work a Cure, following the samemethods as in the Pox" (1709:18).The "Rheumatism" and "nocturnal pains in the limbs"described to Lawson by the Santee correspond well to theepisodes of ostalgia (deep bone pain) that afflict late second-ary and tertiary cases of yaws and endemic syphilis. Theulceration and loss of nasal structures, the ab.sence of urethraldischarge ("gonorrhea"), the responsiveness of the skin le-sions to "mercurial Unguents and Remedies," and the essen-tially self-limiting nature of the disease are also prominentcharacteristics of endemic treponematoses. Zagreb Paleopalhology Symp. 1988 In both series, the demographic profiles of individualsdisplaying skeletal pathology diagnostic or suggestive of en-demic treponemal disease closely matched the demographicprofiles of the series as a whole. Skeletal evidence of thedisease was age-accumulative: older adults were more likelyto bear lesions than were younger adults, adolescents, orchildren. The great majority of the observed lesions werewell remodeled, indicating that the disease was not activearound the time of death.Lawson commented that the Santee "are wholly Strangersto . . . the Phthisick," a term referring to pulmonary tuber-culosis (Jaffe 1972:955). Although it may have been absentin that population, tuberculosis is evidenced by a variety ofskeletal lesions at Moundvilie and at Irene Mound. Of the tenindividuals from Moundvilie with bone lesions diagnostic oftuberculosis, only one displays "classic" vertebral destruc-tion. This young man died in his late twenties, a decade shortof the average adult male age at death. Virtually his entirespine from T3 downward to his sacrum shows pathologicalinvolvement (Figure 8). The bodies of six thoracic vertebraehave been destroyed, producing the anterior kyphosis char- acteristic of spinal tuberculosis or Pott's disease. Numerouslarge round osteolytic lesions with smooth margins appear inthe bodies of several lower thoracic and lumbar vertebrae. Ascompensation for the loss of bone mass, the remaining por-tions of several vertebrae have fused to provide support forthe thorax. Ribs 6 through 10 on both sides display smallshallow osteolytic lesions and poorly remodeled periostitison their pleural aspects. Their necks and heads are considera-bly distorted, with the same combination of destructive andproliferative reaction. No other postcranial tuberculous le-sions were noted, and the skull is unfortunately absent. Theextensive remodeling evident in all areas of pathological in-volvement indicates survival for some considerable length oftime despite severe deformity, as has been abundantly dcKU-mented in modem clinical cases (Myers 1 95 1). 178 ? Mary Lucas Powell Figure 8. Moundville, spinal tuberculosis. Figure 9. Irene Mound, NMNH 385562, lumbar vertebrae,TB lesions. Two mature women from Moundville each bore osteolyticlesions on a single lumbar vertebrae, but such isolated de-struction suggests a diagnosis of blastomycosis rather thantuberculosis (Chick 1 97 1 ). No cases with tuberculous lesionsof the hip, knee, or cranium were observed. However, sevenadults and two subadults displayed rib lesions closely match-ing those described from clinical cases in the Hamann-Toddcollection by Kelley and Micozzi (1984) as characteristic ofchronic pulmonary tuberculosis. The two subadults (agesbirth to 6 months and 7 to 8 years) display extensive, diffuse,unremodeled periostitis on the pleural aspects of multiple right and left ribs. The seven adults were evenly distributedthrough the third, fourth, and fifth decades of life, and alldisplayed lesions at least partially remodeled at death. Wom-en and men were equally represented. This age and sex dis-tribution of adult cases matches that reported in the Hamann-Todd study.In the Irene Mound .series, three cases bear osteolytic le-sions in thoracic or lumbar vertebrae suggestive of spinaltuberculosis. L2 through L5 of a young woman (Figure 9)display extensive shallow lesions on the paradiscal surfaces.T3 and T4 of a second young woman bear deep centrallylocated osteolytic lesions , and L2 through L5 of a young manexhibit widespread circumferential lesions. One older wom-an displayed extensive destruction of her left sacroiliac au-ricular surface with minimal remodeling (Figure 10). Twoadults displayed periostitis on the pleural aspect of the .scapula, and the pleural aspect of the sternum was also sim-ilarly affected in one case.As in the Moundville series, the most abundant extraver-tebral tuberculous lesions were those alTccting the pleuralaspects of the ribs. These lesions appeared in 8 of the 10 cases. In one case focal osteolytic lesions were surroundedby osteoblastic response. Seven of the 8 displayed localizedor diffuse periostitis, illustrated here by the most extremecase (Figure 1 1), the young female adult with multiple lum-bar paradiscal lesions.The mean age at death of the 10 Irene Mound cases withtuberculous vertebral, pelvic, and rib lesions was 29.5 years,five years below the modal sample age of 34.9 years. Oneyoung adolescent, one older adolescent, and four adults aged20 to 24.9 years constituted the younger set of cases. Ap-proximately 15 years separated the oldest of these cases fromthe youngest of the four remaining cases, all in their early tolate 40s. Female prevalence is double that for males, in con-trast to the equal representation of the sexes at Moundville. Conclusions Analyses of archeological data on subsistence and skeletalindicators of nutritional quality at Moundville and IreneMound suggest that both populations enjoyed diets adequateto promote vigorous immune response to infectious disease.The rank-stratified social organization of the Moundvillechiefdom may have created certain dietary differences be-tween elite and non-elite segments of the population, but abroad range examination of the social dimensions of healthand disease at the paramount site revealed no significantdifferences in dental disease or skeletal pathology (Powell1988). The nature and degree of social dilTerentiation at IreneMound have not yet been delineated, but significant rank-determined, dietary inequalities seem improbable (D.G. An-derson, pers. comm. 1987). Good nutrition is a less criticalfactor in resistance to endemic treponematosis than in re- Za^reh Paleopalholo^y Symp. t9SH Treponematosis and tuberculosis in the prehistoric southeastern United States ? 179 Figure 10. Irene Mound. NMNH 385411, SI joint lesion,TB. Figure 1 1 . Irene Mound, NMNH 355562, ribs, pleural peri-ostitis. sistance to tuberculosis (Hackett 1951; Myers 1951), but itsimportance to nonspecific mechanisms safeguarding health(e.g. phagocyte production) should not be forgotten.The human remains excavated from these sites some fiftyyears ago and carefully curated as part of systematic museumcollections in Alabama and Washington, D.C., provide con-vincing diagnostic evidence of the presence of two chronicendemic infectious diseases. Analysis of the patterns of theassociated bone lesions indicates to some degree the breadthof their prevalence within the populations, respecting neitherdemographic parameters nor exalted social rank. But theskeletal record alone cannot convey the full extent of thebiological costs of these insidious and persistent forms ofillness, the toll levied upon each successive generation interms of death, discomfort, deformity, decreased energy, andgeneral debilitation of resistance to other stresses. Each dis-ease followed its own distinctive trajectory from childhoodinfection through subsequent episodes of illness throughoutadult life, the one more blatantly disfiguring and the othermore subtly lethal . The presence of each made the presenceof the other a greater burden to the unfortunate individualswho were doubly afflicted and to the populations in general.Endemic treponematosis was no doubt regarded as one oflife's regular nuisances, while tuberculosis was a rarer but farmore serious matter.An eminent paleopathologist of the author's acquaintancecontinually adjures his students to "remember that a dog mayhave both ticks and fleas," and that differential diagnosisshould always be sensitive to the possibility of multiplepathological conditions simultaneously affecting an individ- ual. To apply this same analogy again in a somewhat differentmanner, the skeletal lesions of endemic treponematosis andtuberculosis may be likened to the parasites visible on a dog'sbody. Their simple presence in terms of the amount of blood Zagreb Paleopathology Symp. 1988 consumed, the burden of their collective weight, and theminor irritation of their bites does not reflect directly themagnitude of their potential impact upon the dog's health.Hidden within them may be agents that produce serious ill-ness or death, depending upon the circumstances surround-ing host and parasites.In similar fashion, the degree of skeletal pathology ob-served does not equal directly the biological costs of thediseases in question, either in terms of numbers of individu- als who were ill or the range of possible symptoms. Clinicalstudies identify numerous cases that would be invisible in thearcheological record. What we actually see in the bones is notthe entirety ofdisease that did exist, but the evidence alerts usto the presence of diseases whose true costs may be inferredfrom the modem epidemiological and clinical literature.In the face of growing political pressure for reburial ofhuman skeletal remains in the United States and elsewhere,paleopathologists should feel a particular obligation to bringto bear our most sophisticated theoretical and methodologi- cal capabilities to investigations of the dimensions of healthin the prehistoric past. Differential diagnosis provides a pow- erful tool for conducting such analyses, and to ignore its fullpotential is to deliberately limit the contributions of our re-search. Acknowledgments This paper is the result of numerous discussions with Donald J. Ortner, my advi.sor during a Postdoctoral Fellowship at theSmithsonian Institution, about the problems and potential ofinterpretation of skeletal disease. 1 have benefited greatlyfrom his sophisticated insights into critical issues, and he iscoauthor in fact, if not in name. Misinterpretations of thedata, however, are solely my own. 180 ? Mary Lucas Powell Literature cited Alland, A. Jr. 1970. Adaptation in Cultural Evolution: An Ap-proach to Medical Anthropology. New York; Columbia Univer- sity Press.Armelagos, G.J., A. Goodman, and K.H. Jacobs. 1978. The Eco-logical Perspective in Disease. In M.H. Logan and E.E. Hunt Jr..eds. , Health and the Human Condition: Perspectives on MedicalAnthropology. 71-84. North Scituate. Mass.: Duxbury Press.Buikstra. J.E., ed. 1981. Prehistoric Tuberculosis in the Americas.Northwestern University Archaeological Program, Scientific Pa-pers, 5. Evanston. III.: Northwestern University.Buikstra, J.E., and D.C. Cook. 1980. Paleopathology: An Ameri-can Account. Yearbook of Physical Anthropology. 20:316-328.Burnet, Sir M., and D.O. White. 1972. Natural History of Infec-tious Disease. Cambridge, U.K.: Cambridge University Press.Chick. E.W. 1971. North American Blastomycosis. InR.D. Baker, ed.. Human Infections with Fungi, Aclinomyceles and Algae,465-506. New York: Springer-Verlag.Cockbum, A. 1973. Infectious Di-ieases. Their Evolution andEradication. 2d edition. Springfield, III.: Charles C Thomas.Greenfield. G.B. 1980. Radiology of Bone Diseases. 3d edition.Philadelphia: J.B. Lippincott.Grin, G.I. 1953. Epidemiology and Control of Endemic Syphilis:Report on a Mass-Treatment Campaign in Bosnia. World HealthOrganization Monograph, 1 1 . Geneva.1956. Endemic Syphilis and Yaws. Bulletin of the WorldHealth Organization, 15:959-973.Hackett, C.J. 1 95 1. Bone Lesions of Yaws in Uganda. Oxford:Blackwell Scientific Publications.1976. Diagnostic Criteria of Syphilis, Yaws and Trep-onarid (Treponematosesj and of Some Other Diseases in DryBones. Berlin: SpringerVerlag.Hoeprich, P.D., ed. 1977. Infectious Diseases, a Modern Treatiseon Infectious Proces.ses. 2d edition. New York: Harper and Row.Hrdlicka, A. 1909. Tuberculosis among Certain Indian Tribes of theUnited States. Bureau ofAmerican Ethnology Bulletin, 42.Hudson, E.H. 1958. Non-Venereal Syphilis, a Sociological andMedical Study of Bejel. Edinburgh: E. and S. Livingstone.Jaffe, H.L. 1972. Metabolic. Degenerative, and Inflammatory Dis-ease of Bones and Joints. Philadelphia: Lea and Febiger.Kelley, M.A., and M.S. Micozzi. 1984. Rib Lesions in ChronicPulmonary Tuberculosis. American Journal of Physical An-thropology. 65:381-386.Lawson, J. 1709. A New Voyage to Carolina. London.McNeill, W.H. 1976. Plagues and Peoples. New York: AnchorPress. Murray, J.F. , A.M. Merriweather, and M.L. Freedman. 1956. En-demic Syphilis in the Bakwena Reserve of the BechuanalandProtectorate. Bulletin ofthe World Health Organization. 15:975-1039.Myers, J. A. 1951. Tuberculosis among Children and Adults. 3d edition. Springfield, III.: Charles C Thomas.Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho-logical Conditions in Human Skeletal Remains. SmithsonianContributions to Anthropology. 28. Washington, D.C: Smithso-nian Institution Press.Peebles, C.H. 1978. Determinants of Settlement Size and Locationin the Moundvillc Phase. In B.D. Smith, ed., Mississippian Set-tlement Patterns. New York: Academic Press.Powell, M.L. 19&S. Status and Health in Prehistory: A Case Studyof the Moundville Chiefdom. Washington, D.C: SmithsonianInstitution Press.1990. On the Eve of the Conquest: Life and Death at IreneMound, Georgia. InC.S. Larsen, ed., The Archaeology of Mis-sion Santa Catalina de Guale: 2. Biocultural Interpretations of aPopulation in Transition, 26-35. Anthropological Papers of theAmerican Museum ofNatural History.Robbins, S.L., and R.S. Cotran. 1980. Pathologic Basis of Dis-ease. 2d edition. Philadelphia: W.B. Saunders.Steinbock, R.T. 1976. Paleopathological Diagnosis and Interpre-tation. Springfield, III.: Charles C Thomas.Turner, T.B., and D.H. Hollander. 1957. Biology of the Trep-onematoses. Geneva: World Health Organization. Summary of audience discussion: The absence of skull involve-ment by tuberculosis in this study is consistent with the paucity ofreported cases both in ancient and in modem populations. Prior tothe availability of effective chemotherapy, tuberculous meningitiscertainly was not rare , and the primarily cortical response which onewould expect ought to be easily separable from the "caries sicca"lesion characteristic of cranial treponematosis. It is conceivabletuberculous periostitis is present more frequently than reported butoverlooked because the lesions may be small, of nonspecific struc-ture and difficult to see in an intact skull because of their endocranialposition. The rapid course of tuberculous meningitis in modempopulations also probably provides insufficient time for develop-ment of the osseous reaction. Since a slower course would imply thedevelopment of greater resistance to the tubercle bacillus, it is un-likely that its course was any slower in antiquity. Zagrffe Paleopathology Symp. 1988 Vertebral tuberculosis in ancientEgypt and Nubia Eugen Strouhal It has become a widely accepted view that diagnosis oftuberculosis from archeologically excavated human skeletalremains is not easy, but that a reasonably reliable predictioncan be made if the spine is involved (Haneveld 1980:2).Vertebral tuberculosis (spondylitis tuberculotica) was firstdescribed by Sir Percival Pott, a surgeon at St. Bar-tholomew's Hospital in London, in 1779 (Pott 1790) andnamed malum Potti in honor of him. It deserves to be studiedby modem paleopathologists also 200 years later. Its patho-logical anatomy is usually very characteristic, making it pos- sible to distinguish it from other spinal diseases.While modem clinical reports indicate that skeletal tuber-culosis as a rule occurs as a complication secondary to eitherpulmonary or intestinal tuberculosis in about 1% of suchpatients, its incidence was considerably higher during thepreantibiotic era: between 5 and 7% (Steinbock 1976:175;Zimmerman and Kelley 1982:103). In the same period thespine was involved in 25-50% of skeletal tuberculosis cases(Steinbock 1976:176). This means that cases of skeletal tu-berculosis represent about 1-3.5% of the total number ofpeople who were infected by tuberculosis. It is encouraging that the acid-fast bacterium Mycobac-terium tuherculosis (bacillus Kochi) was recently demon- strated in a Peruvian mummified child of the seventh centuryA.D. Nasca culture (Allison et al. 1973) as well as in thevertebrae and pulmonary blood of an Egyptian mummifiedchild from Thebes West, dated 1000-400 years B.C. (Zim-merman 1977,1979). Nevertheless, bacteriological tech-niques can be used only exceptionally in excavated materialand the agent of the disease is not always preserved in it. Forcurrent studies on the incidence of tuberculosis in ancient[xjpulations, however, macroscopic and radiological diag- nosis of cases of vertebral tuberculosis may still be used asconvenient and technically simple methods. The presence of vertebral tuberculosis has to be considered at the same timeas evidence for the presence of other tuberculotic forms, suchas pulmonary, intestinal or glandular, without, however, re-vealing their specitlc frequencies (Grmek 1983:265). Zagreb Paleopathology Symp I9HH Moreover, the description of each newly detected caseadds some new knowledge to the morphology, extent, andcourse of the disease. This applies to two cases recentlyfound in a Middle Kingdom burial in Egypt (case no. 1 ) andin a Christian period cemetery in Nubia (case no. 2). They areof interest because of their considerable extent and contrast-ing developmental phases, pointing to different social im-plications. Case number 1 ARCHEOLOGICAL BACKGROUNDAn isolated secondary burial of Middle Kingdom dating wasfound in the 5th dynasty Pyramid Temple of King Raneferef at the royal cemetery at Abusir by the mission of the Czecho-slovak Institute of Egyptology, Charles University, Prague,in 1984. The burial of a male called Khuyankh (Hwy'nh)(900/1/84) was placed at the bottom of a rectangular shaftexcavated in the northern half of room AA-Ec, situated in theNE comer of the hut-nemet section of the temple. The lowerpart of the shaft was lined with sun-dried bricks delimitingthe burial chamber, oriented with its longer axis roughly N-S . As no traces of roofing were detected, it seems probable that after insertion of the cotTins the shaft was simply filled upwith sand.The dead individual was provided with two coffins. Theexternal, box-shaped one was decorated on its outer surfaceby inscriptions, and on its interior sides by further in.scrip-tions, coflfin texts, and pictures of offerings. The intemal,anthropoid coffin was lying on its left side inside the externalcoffin with the head end to the north. The skeleton, 155 cmlong, was in an extended position at the bottom of the inner coffin with the skull tumed with its face down.In the inner coffin two faience beads and the head of awooden stick were found. South of the foot end of the outer coffin a low chest was placed, divided by two boards intofour compartments with remnants of organic matter and181 182 ? Eugen Strouhal wrappings on their bottom. A large, globular storage vesselstood in the NE comer of the burial chamber. EMBALMING METHOD Several black spots could be observed on the skull. Bones ofthe lower extremities (except the missing femora) werestained with a dark, almost violet color. Both are traces of resin used to smear the wrappings during embalming. Sometextile fragments with pieces of stiffened resin were foundamong the bones and fragments of wood of the inner coffin.Remnants of dried brain were still present in the cerebral cavity. The nasal skeleton was found intact. Both these find-ings attest that brain removal was not performed, being re-served only for persons of royal or high official rank duringthe Middle Kingdom times (Strouhal 1986:145). AGE Cranial sutures showed a progressive state of obliteration(C3, S2 -(- 3, LI + 2). The complete dentition (with onlycrowns of right upper C and left upper I 1 and 2 broken off)was considerably abraded, ranging from points of exposeddentine on lower M3 to complete removal of the crowns onupper left C and upper right premolars, but without pulpexposure. A caries lesion was present on the left lower M2,destroying the distal half of the crown and, through involve-ment of the pulp, causing a great, longitudinally orientedoval cyst opening on the outer aspect of the alveolar process(13 X 7 mm, depth 7 mm). Resorption of the alveolar processwas of medium degree according to the scale of Brothwell(1963:150). Considerable deposits of dental calculus wereaccumulated on the upper left molars and on all lower premo-lars both buccally and lingually, and on the lower molarslingually. Medium large deposits were present on the upper right molars lingually (according to the scale of Brothwell).All epiphyseal and apophyseal fissures of the postcranialskeleton were completely fused. Pubic symphysis relief re-sembled phase 8 of Todd (1920) pointing to the range of 39-44 years. No synostosis of the sternal parts occurred. Onlybeginnings of lipping on the left humeral head and a ruggedsurface of the tubercula minora could be observed. Thefemora were missing. Slight osteophytic outgrowths werepresent on the patellae, and some of medium size on thecalcanei. No arthritic changes were apparent in any joint.The grade of vertebral osteophytosis in sections not directlyinvolved in the pathological changes to be described (CI -7,T 1 -8 , L2-5 , S 1 ) was mostly of medium degree (osteophytesmore than 3 mm long but not bridging) or slight (osteophytesless than 3 mm). Spondylarthrosis could be detected in jointsT6-7 and T7-8 and osteochondrosis of intervertebral discsbetween C5-6 and C6-7, both probably related to the mainpathology of the spine.According to the described features the individual diedbetween 40 and 50 years of age. SEX In spite of only a slightly developed glabella (Broca 2) andsupraorbital arches (Eickstedt 2) as well as of nasofrontaltransition on a medium curved arch, most other secondarysexual features pointed to the male sex. There was a slightlyoblique forehead, a medium protuberantia occipitalis externa(Broca 2), a medium thick and long mastoid process with adeep incisura mastoidea, a medium thick upper orbital mar-gin, slightly to medium developed marginal process, a well-developed muscular relief of the nuchal and mandibular re-gions, a slightly averted mandibular angle, and a broadsquare chin. In addition moderately developed apophyses ofthe pelvis, a medium deep and large ischiatic notch, absenceof a preauricular sulcus, a big oval foramen obturatum, a sagittally narrow pelvic inlet, an outstanding pubic tubercle, a flaring lower aspect of the pubic bone, an acute subpubicangle (50?), and a low ischio-pubic index (left 65.0, right61.3, according to Thieme and Schull 1957:269) all indicatethe male sex unequivocally. GENERAL PHYSICAL FEATURES The body build was moderately robust, with musculaturedeveloped to a medium degree on the lower limbs and slightly less developed musculature on the upper limbs. Sta-ture was reconstructed according to the tables of Trotter andGleser ( 1 952) for American Negroes, which were found to fitbetter to proportions of the Nubians (Strouhal and Jungwirth1984:119-122) as well as Egyptians (Robins 1983:17-20),and appeared high (171 .4 cm). SPINAL PATHOLOGY The vertebral column viewed from the sides was stronglybent in the lower thoracic third (Figures 1 ,2). The bodies offive vertebrae?T9 to LI?were completely merged andtheir neural arches, intervertebral joints, and ventral portionsof the interspinous ligaments (the last except TlO-1 1, Fig-ures 3-5) were also fused. While the body of LI retained itsindividual shape, bodies of the last four thoracic vertebraehad almost disappeared and their remnants joined into anuniform, wedge-shaped formation (anterior height 2 mm,posterior height 36 mm) merging with the wedge-shapedbody of LI (anterior height 7 mm, posterior height 20 mm).The radiogram (Figure 6) revealed a regular, strain-conditioned trabecular structure without remnants of residualcavities or intervertebral spaces. The right side of the forma-tion was covered by a thin layer of newly formed bone withfine, radial ridges on its surface. The left side was strength-ened by a thickly ossified lateral longitudinal ligament, en-compassing also the 1 0th costovertebral joint.Vertebra T8 also had a wedge-shaped body (anterior height5 mm, posterior height 20 mm) and it was firmly fused withthe mentioned formation in intervertebral joints as well as by Zagreb Httleopathology Symp. I9H8 Vertebral tuberculosis in ancient Egypt and Nubia ? 183 ABUSIR3CC/l/8'i Figure 1 . Case no. 1 . Thoracic spine with LI showingstrongly arched deformity ofT8-L1 , right lateral view. ABUSIR Figure 2. Case no. I. Lower third of thoracic andlumbar spine showing arched deformity of T8-L1, right lateral view. >'^-^-^% , V Figure 3. Case no. 1 . Wedge-shaped T8 and fused mass ofbodies T9-12 united with Li, right lateral view. Zugreh Faleopalhalugy Symp. 1 988 Figure 4. Case no. I. Owing to a bend of 130?. upperterminal plate of T8 and lower terminal plate of LI with adeep depression are visible in frontal view. 184 ? Eugen Strouhal Figure 5. Case no. 1. Deformity covered by ossified leftlateral longitudinal ligament, encompassing 10th costover-tebral joint. ossification of the interspinal ligament. The intervertebralspace T8-9 was preserved (height 2 mm) and there was also awavy chink dividing the ossified left lateral longitudinal liga-ment. The right side of the body of T8 was bare.Intervertebral openings and the spinal canal did not showany reduction that could have caused neurological problems.The course of the vertebral column was deformed both inthe frontal and sagittal planes. There was a slight, S-shaped scoliosis, sinistroconvex in the lumbar and lower thoracicsections, dextroconvex in the upper thoracic half.The kyphotic angulation reaching 1 30? appeared more im-portant. To compensate for this protuberance, the remaining,healthy lumbar vertebrae showed increased anterior heightscompared with their posterior heights (L2 36/26, L3 34/30,L4 32/28, L5 32/26 mm). At the same time, the physiologi- cal thoracic kyphosis was reversed into a compensatory lor-dosis, in the section not involved in the pathology, by asimilar increase of anterior heights compared with the pos-terior ones (T3 21/19, T4 20/18, T5 22/20, T6 23/20, T722/21 mm). The remaining correction of the upright posturemust have been achieved by hyperlordosis of the cervicalspine and dorsal flexion of the head . Also with these compen-satory adaptations, the position of the lower thoracic spinewas almost horizontal , causing deformation of the thorax andheavy pressure on thoracic and abdominal internal organs.The spinal deformation lowered substantially the living sta-ture of the man. The difference between the value calculated Figure 6. Case no. 1. Radiogram of right sacroiliac an-kylosis (afcovej, axial projection, and fused vertebrae T8-L1(below), lateral projection. according to lengths of long bones and the measurement ofthe body length in situ was 16.4 cm. In spite of thesechanges, the hunchback was able to walk (possibly with thehelp of a stick, whose head was put into his inner coffin) andwork.The described changes could, by the unnatural twist of thespine, also have caused deep, oval depressions on terminalplates of the neighboring vertebrae LI + 2 and L2 -I- 3, signsof the prolapse of the nucleus pulposus of the intervertebraldiscs (Figures 4,5). Osteochondrosis of the intervertebraldiscs C5-6 and C6-7 and spondylarthrotic changes in thejoints T6-7 and T8-9 may also have been associated with theadaptive changes of the gravity of the thoracic spine. SACROILIAC SYNOSTOSIS The right sacroiliac joint was ankylosed by means of a thicklayer (up to 4 mm) of newly formed bone covering the ante- rior half of the upper margin and the upper half of the anteriormargin of the facies auriculares (Figures 6,7). The remainingmargins and the inner space were free. The left sacroiliacjoint presented osteophytic lipping on the margins of bothfacies auriculares (2-5 mm). These changes could have beenadaptive, strengthening the basis of the deformed spine. Zagreb Paleopathology Symp. 1988 Vertebral tuberculosis in ancient Egypt and Nubia ? 185 Figure 7. Case no. 1. Synostosis ofpart of right sacroiliac joint, cranialview. ABUSIR OSTEOMA ON THE RIGHT FIBULAA longitudinally oriented oval, roundish protrusion (18 x 10mm, elevated 4 mm) was situated at the medial aspect of thedistal end of the right fibula. Its surface was covered bycompact bone, smooth or slightly uneven. CONGENITAL ANOMALIESA bilateral small foramen arcuatum atlantis (diameter 1 mm)was combined with bilateral, anteriorly open foramina trans- versalia atlantis. The left foramen transversale epistropheiwas also open laterally and there was an anomalously smallopening (diameter 2 mm) at the site of the right foramentransversale. DIAGNOSIS OF THE SPINAL PATHOLOGY. Features considered to be characteristic for spinal tuber-culosis in current paleopathological literature have beencompared for both cases in Table 1 . Leaving aside age andsex, there are 20 features of which the majority fit for caseno. I. There are, however, seven features which disagreewith the scheme and need to be explained.The extent of the pathology usually involves two to fourvertebrae (Manchester 1983:40; Zimmerman and Kelley1982:105), but occasional cases may involve considerablymore (examples are quoted by Zimmerman and Kelley1982:105), as shown by our case. Lack of the progressiveerosion of the circumferential surface of vertebral bodiesbetrayed the termination of the activity of the disease. Thesame applied for the absence of a recent central abscesscavity in any of the vertebrae. In the course of the process,which was limited only to vertebral bodies, no changes lead- Zafirrb Paleopatbolony Symp. 1988 ing to narrowing of the intervertebral openings or of theneural canal occurred. Paravertebral abscesses, derived fromoriginal abscesses in vertebral bodies T8-L1 , apparently didnot affect any bony surface to leave observable changes. Notevery patient with tuberculosis must be emaciated. Our caseindicates a successful course of the disease thanks to theextraordinary resistance of the host.The strong kyphotic curvature observed in our case, in-stead of an angular nick, also can be reconciled with thediagnosis of .spinal tuberculosis. It was the result of summa-tion of six lesser angular kyphoses which gradually devel-oped after evacuation of the abscesses and pathological frac-tures of bodies of the afflicted vertebrae. COURSE OF THE DISEASEThe infection must have begun early in childhood as evi-denced by the adaptive greater increase of anterior heights ofthe healthy vertebrae. It is well known that before the devel-opment of an effective therapy, vertebral tuberculosis devel-oped during the first decade of their life in 50-10% of tuber-culous children and usually appeared 9 months to 2 yearsafter the primary infection (Ulrich-Bochsler et al. 1982: 1 322). Other authors also stress the onset in early childhood,mostly before 7 years of age (Ortner and Put,schar 198 1 : 145).From the beginning of the disease in his first decade of lifethe affiicled man lived 30-50 more years, during which com-plete healing occurred except for the preservation of the de-formity of the spine by firm fusion of the remnants of theinvolved vertebral bodies. It seems highly probable that dur-ing this long period his immune response succeeded in sub-duing also other possible manifestations of bacillus Kochi inhis other organs. 186 ? Eugen Strouhal Table l. Comparison of characteristic features of spinal tuberculosis ofcases 1 and 2 Feature Vertebral tuberculosis in ancient Egypt and Nubia ? 187 on terminal plates of the cervical vertebrae, between other sacral bodies, along the cristal and ischiatic apophyses, onhumeral and femoral heads as well as on the distal ends of radii, ulnae and fibulae. The pubic symphysis showed pha.se3 of Todd ( 1920) having the range of 22-24 years. Parts ofthe sternum were not fused. No age-dependent changes couldbe found on the proximal ends of both humeri and femora,except some rugged relief medially on the crista tuberculimaoris, caused by muscular action. There was no arthritis,no patellar and only beginning calcaneal osteophytes. On vertebral bodies whose margins were not eroded by thepathological process to be described (CI-T4, L2-5, SI ) nolipping was present except slight beginnings on C4 and C5.Also the intervertebral joints were intact except in the regionmostly involved in the pathology, where an arthrosis of T9-10 and synostosis T 1 0-1 1 developed.The described features agree with a young adult age of 22-24 years. SEX In spite of an only slightly developed glabella (Broca 2) andsupraorbital arches (Eickstedt 2) as well as a nasofrontaltransition in an only slightly concave arch and a very feebleprotuberantia occipitalis externa (Broca I), other featurespointed to the male side. There was a smoothly arched fore-head, a thick and long mastoid process, a small and shallowincisura mastoidea. situated within the mass of the process, amoderately thick orbital margin, a slightly to moderatelydeveloped processus marginalis, a slightly to moderately de-veloped nuchal, but a medium to strongly marked mandibu-lar muscular relief with a large eversion of the mandibularangle. Also moderately large pelvic apophyses, a deep andnarrow ischiatic notch, absence of a preauricular sulcus, anoval, moderately large pelvic inlet, an outstanding tuber-culum pubicum, a flaring lower aspect of the pubic bone, a rather acute subpubic angle (60?) and a low ischiopubic index(left 64.0, right 63.6, according to Thieme and Schull1957:269) argued unequivocally for the male sex. GENERAL PHYSICAL FEATURES The body build was moderately robust to robust with well-developed muscular insertions. Stature, reconstructed ac-cording to tables of Trotter and Gleser (1952) for AmericanNegroes, was medium (166.1 cm). SPINAL PATHOLOGY In contrast with case no. I , the whole thoracic and lumbarspine showed a lytic process with inhibition of new boneregeneration, progressing from above downward in the thor-acic and from below upward in the lumbar section with max-imum changes in TIO-LI, resulting in a double angularkyphosis (Figures 8-13). Multiple small, larger, and big Zu^reb Faleopalholony Symp. I98S Figure 8. Case no. 2. Upper thoracic spine with lyticchanges on vertebral bodies, right lateral view. confluent cavities were characteristically localized on thecircumferential aspects of the vertebral bodies, portrayingthe hematogenous spread of the infection via the paraver-tebral plexus and anterior longitudinal ligament (Zimmer-man and Kelley 1982:105).The cervical spine was devoid of pathological changes.The upper third of the thoracic spine showed eroded pits onthe vertebral bodies, whose original shape had been mostlypreserved. In the middle part of the thoracic spine the de- struction by confluent foci reached such an extent that onlystumps of vertebral bodies remained. They had bizarre formsof columns bordering deep cavities and perforations. Theprocess did not penetrate into the neural arch and no changeswere present on intervertebral joints.The lower part of the thoracic spine was maximally af-flicted by the pathology. The lytic process removed the wholebody of vertebra TIO and eroded the anterior parts of thepediculi arcus vertebrae. The anteroposterior axis of the ver-tebra had been rotated 70?, and consequently the spinousprocess ofT9 became the salient point of an angular kyphosis(90?). Intervertebral joints T9- 10 were enlarged and eroded 188 ? Eugen Strouhal ^4.IT ^jpr Figure 10. Case no. 2. Lower thoracic spine with lyticchanges and angular deformity of T 10- 12, right lateral view. Figure 9 (left). Case no. 2. Upper thoracic spine with lyticchanges on vertebral bodies, frontal view. -^^rCo Figure II. Case no. 2. Lower thoracic spine with lyticchanges, completely destroyed body Tl 0, and wedge-shapedbody Til, frontal view. -W"= ?t Figure 12. Case no. 2. Lumbar spine with wedge-shapedLI, lytic cavities in body L2, and more or less pitting inbodies L3-5, right lateral view. Zagreb Paleopathology Symp. 1988 Vertebral tuberculosis in ancient Egypt and Nubia * 189 Figure 13. Case no. 2. Lumbar spine withwedge-shaped LI, lytic cavities in bodyL2, and more or less pitting in bodies L3- Figure 14. Case no. 2. Radiogram of spine showing lytic changes and double5, frontal view. angular kyphosis, which together equals 140?, lateral projection. (spondylarthritis), while joints TlO-ll were completelyfused (synostosis). These changes were secondary to un-usually heavy strain.The wedge-shaped vertebra Tl 1 (anterior height 4 mm,posterior height 20 mm) showed in its center a large abscess cavity, bordered by lateral pillars of the remaining spongiosa,thicker right (8-1 1 mm) than left (5-6 mm). Thebody of thisvertebra filled the empty space in the place of the destroyedbody TIO by rotation of the anteroposterior axis of the ver-tebra including 90? with the axis of T9. Articular facets of theintervertebral joint TII-12 were enlarged but not eroded.Vertebra T12 retained its original shape, but its wholesurface had been eroded by several large and partly merging cavities. Small saucer-shaped erosions penetrated also intoboth pediculi arcus vertebrae. Intervertebral joints TI2-LIdid not show any change.Another wedge-shaped vertebra L 1 (anterior height 3 mm,posterior height 21 mm) revealed that the lytic prwess con-tinued after the evacuation of the abscess and healing of thepathologically fractured vertebral body. There were severalsmall or medium cavities and erosions on its surface (upper, right lateral, and lower margin). Even both pediculi arcusvertebrae were perforated from above (5x7 mm) downward Zagreb Paleopathology Symp. 1988 (1x1 mm) and the anterolateral side of the right processus articularis superior showed two tiny "borings." Owing to thewedge shape of L 1 , its spinous process was the top of anotherangular kyphosis of the spine (50?).Vertebra L2 retained its original shape, but several large cavities penetrated its surface (anteriorly left of the midline,on the left and right anterolateral aspect) together with small-er pits and erosions.The following vertebrae L3-5 showed a decreasing quan-tity of pitting, on a few places merging into larger defects.Here we could observe well the progress of the describedprocess. All lumbar intervertebral joints were intact.The axis of the spine deviated in the sense of a dex-troconvex scoliosis of the lower thoracic section. More im-fwrtant, however, was the double kyphosis in the thor-acolumbar transition reaching collectively an incredible 140?angle. The deformation of the vertebral column can be seenon the radiogram (Figure 14) together with the extent oferosion and destruction of the individual vertebrae. Becauseof absence of a compensatory growth of the vertebrae in thesense of an adaptive lordosis, the thoracic spine starting at thethoracolumbar bend in vivo was sinking from above back-ward to downward and forward in a very oblique position. 190 ? Eugen Strouhal Figure 15. Case no. 2. Eroded areawith new bone overgrowth on innerside of right iliac wing, frontal view. ''1 Vertebral tuberculosis in ancient Egypt and Nubia ? 191 DIAGNOSISComparing characteristic features of tuberculosis in case no.2 with case no. 1 (Table 1), we find differences in more thanhalf of them. Case no. 1 findings indicated a long durationwith prevalence of adaptive changes and healing. In contrastto this, case no. 2 showed a relatively short-term and active,predominantly lytic process with very limited healing.At the same time, with half of the features there seems tobe a disagreement with the usual diagnostic set for tuber- culosis. This applies first to the extraordinarily great extentof the process, involving altogether 17 vertebrae with majorchanges in four of them. From the recent literature two caseswith similarly elevated numbers of afflicted vertebrae can bequoted. The first one from Oberweil bei Buhren a.d. Aare(Switzerland), dated 7th-8th century a.d., was that of an18-23-year-old woman afflicted by a destructive-reparativeprocess involving 13 vertebrae, C7 and all thoracic withmaximum changes between T4 and T6 (Ulrich-Bochsler et al. 1982:1318-1319). A juvenile male aged about 15 yearsfrom Arene Candide Cave (Liguria, Italy), dated beginningof the 4th millennium B.C., showed resorptive lesions ineight vertebrae (T9-L4) with a maximum of destruction be-tween TIO and LI (Formicola et al. 1987:3). Cases with agreat extent of the process most probably reflect the greatvirulence of infection and the limited resistance of the host.In agreement with that we found the uncommon involve-ment of anterior sections of the neural arch (pedicles and articular processes) which characterizes very severe cases(Zimmerman and Kelley 1982:105).Because the process was relatively rapid and destructiondominated production of new bone, there was not enoughtime and resistance for the development of fused vertebralbodies, ossification of interspinous or lateral longitudinalligaments, apposition of new-formed bone, or fusion of cos-tovertebral joints. Steady progression of the destruction overhealing was revealed especially in LI whose "healed" wedgeshape was eroded anew by suppuration.The process did not nartow the neural canal, but did in-volve a single intervertebral opening. Absence of compensa-tory growth of vertebrae was connected with the later begin-ning of the disease and lack of emaciation together with its relatively short duration. psoas abscesses is attested by the bilateral development of thedemarcated iliac periostitis. The patient did not developenough resistance and the infection spread both in the cranialand caudal directions gradually involving more and more vertebrae.Due to the severity of the infection and the extreme gradeof deformation of the trunk we may be almost sure that thepatient died as the result of it or from some of its complica-tions. The mortality of tuberculosis in the preantibiotic erawas 50% and most often occurted in the first two decades oflife. Today it is about 5% and confined to an adult or senileage (Ulrich-Bochsler 1982:1322). DIFFERENTIAL DIAGNOSIS The absence of pathological changes in the remaining skel-eton, revealed macroscopically and by the x-rays, as well asthe evidence of the psoas abscesses are strong argumentsagainst other diagnostic possibilities (Steinbock 1976:176,179). The multiplicity of lytic foci in such a great number of vertebral bodies could be produced by blastomycosis, but in it the lesions are almost only destructive, with a punched-outappearance and with little new bone growth. It involves alsoneural arches and, beside the spine, affects ribs and otherbones (Zimmerman and Kelley 1982:89). In pyogenic os-teomyelitis of the spine such a great extent and massive de- struction of several vertebral bodies leading to an angularkyphosis and paravertebral abscesses are uncommon (Ortnerand Putschar 1981:149). The pus, penetrating bone cortex,leads to new bone formation with irtegular thickening andcloacae in the involucrum (Zimmerman and Kelley 1982:93-94). SOCIAL IMPLICATIONSThe rapid progression and severity of the process forced thepatient to lie in his bed and be nursed by his family or neigh-bors. The exaggerated deformity of the spine with extremecompression of internal organs prevented standing, walkingand working. He became fully dependent on social support.This state did not last, however, for a long time. The shortcourse of the disease is reflected in the preservation of his relatively robust and muscular body. COURSE OF THE DISEASEOur young man caught the disease after the end of his growthperiod, since otherwise adaptive increase of anterior heightsof vertebrae would have appeared. With regard to his age atdeath, there is a span of about seven to nine years in which theprocess could occur. It seems, however, probable that itlasted for a far shorter period. Most probably the body of TIOwas first destroyed, later an abscess involved the left LI, andfinally another abscess was evacuated from Til, leavingthere remnants of its cavity. More than a single extension intoZannb Paleopalhotogy Symp. 1988 Literary data on vertebral tuberculosisin Egypt and Nubia Since it is a disease of at least neolithic antiquity, associatedwith drinking milk of cows infected by the bovine type ofMycohacterium tubercuhsia, from which the human typedeveloped later by microevolution (Manchester 1983:39-40), the occurrence of tuberculosis in ancient Egypt andNubia may well be expected. Milking there became veryimportant as expressed in the widespread cult of the cow-goddess Hathor, and there was a high population density in 192 ? Eugen Strouhal crowded villages and towns which enabled close contact ofpeople and easy transmission of the agent.Three different sources of information, scattered in theliterature, may be consulted for a survey of the presence of vertebral tuberculosis: iconography, excavated skeletal re-mains, and mummies. ICONOGRAPHY Several statues and drawings of hunchbacks may be found inEgyptian art (Morse et al. 1964:525-528; Morse 1967:263;Baud 1978:pl.l6). Their evidence is, however, ambiguous.Diagnosis of vertebral tuberculosis can be based only on theshape of the kyphosis. If it is angular, the probability oftuberculous origin is great. If it is arched, other diseases suchas rachitis, Scheuermann's disease, osteoporosis, and badbody posture also must be taken into account.Better information may be gained in plastic art. The diag-nosis of vertebral tuberculosis is suggested in an allegedlypredynastic clay statuette of an emaciated man with a thor-acic angular kyphosis found inside a bowl (Morse et al.1964:524-525), a possibly predynastic standing, ivory fig-ure showing protrusion of the back and chest (Morse et al.1964:525), a probably Archaic statuette of a squatting,bearded man with a thoracic angular protuberance and anangular protrusion of the chest (Jonckheere 1948), and awooden statue from the Cairo Museum with an angularkyphosis on the transition between upper and middle third ofthe thoracic spine (Ghalioungui and Dawakhly 1965:20,fig.64).In drawings, evaluation is more complicated, because thehunchback can also be factitious due to artistic ineptitude and stylistic convention. In Egyptian pictures, human shoulderstraditionally were represented in frontal view and if the artistfailed to place one of the arms correctly the protruding shoul-der may resemble a strongly arched hunch, situated high onthe spine. This can be the case of the representation of the "deformed" gardener from the New Kingdom tomb of Ipuy(Davies 1927:pl.XXIX), of the relief of the priest Ankhutusfrom the false door of his Old Kingdom tomb (Mogensen1930:90, pi. XCV), as well as of the relief of a servant leadingtwo dogs in the Ti's Vth dynasty tomb (SteindorflF 1913:pi. 1 15). Only the relief of a serving girl from tomb no. 45 atGiza, dated IVth dynasty, shows a strongly arched thoracicprotuberance (Vandier I964:rig.2), and the painting of anattendant from a Xllth dynasty tomb at Beni Hasan demon-strated a protruding, arched hump at the cervicothoracic tran- sition, both suggesting tuberculous origin. SKELETAL REMAINS Altogether, 30 cases of vertebral tuberculosis were gatheredin the last reviews of tuberculosis in ancient Egypt by Morse et al. (1964:529-540) and Morse ( 1967:263-268). There are13 cases from the Upper Egyptian site at Nagada with "typi- cal pathological changes to be considered as tuberculosis andseven of them . . . quite typical" (Morse 1967:268). Unfor-tunately, their dating is problematic. While some are pre-dynastic (B 107, T 52), others may come from dynastic timesupto 1400 B.C. In six cases (B 107,60, 1003, D5, R, andQ)the diagnosis of tuberculosis seems to be less probable, andother causes (such as acute osteomyelitis or healed com-pressed fracture) were also taken into consideration (Morseetal. 1964:535-539).Of the nine cases described by Derry (1938:1) and sum-marized in a table by Morse (1967:264) only two were fromEgypt, one found in an aged woman from Saqqara dated asearly as 3300 B.C. , and the other in an old woman from Deirel-Bahri dated 1500 B.C. Seven other cases come fromNubia, most of which are dated 3000 b.c. , and in case no. 1 , 2000 B.C. Four adult men, two adult women and a nine-year-old boy were afflicted. Epidemiologically interesting are twograves, each containing remains of two tuberculous individu- als (a man with a woman in tomb no. 314, and a man with aboy in tomb no. 452).A series of six unfortunately isolated Nubian vertebralspecimens were described by Morse et al. (1964:531-534)and summarized by Morse (1967:265). One of them listedunder catalog no. 1 82 E, together with vertebrae of two otherpersons, is identical with Derry 's case no. 1 , being a lumbarvertebra with a large smoothly delimited cavity more sugges-tive of a bone cyst or osteolytic neoplasm (Morse et al.1964:533, fig. 9 above right) and should be excluded.Another case of vertebral tuberculosis was described bySmith (1927:24) and quoted by Morse et al. (1964:534). butinsufficiently quoted by Morse (1967:265,267). In the in-complete remains of Pa-Ra'messu, the son of Seti I andbrother of Ramesses II, aged 26-30 years, a mass consistingof six thoracic vertebrae (probably T4-9) with parts of corre-sponding ribs was found, all firmly ankylosed together. Thebodies of the middle vertebrae had collapsed causing a right-angle bend between probably T6-7. Smith associated withthis process the slendemess and gracility of the left leg com-pared with the right one.The case described by Watermann (1960:170-171) hasbeen misquoted by Morse et al. (1964:531) and Morse(1967:264) as originating at Giza and excavated by AbuBakr. In reality it was found in a prehistoric grave and storedin the Museum of Helwan. Two fused sections of the spinewere apparent, the first between T4 and T7 with wedge-shaped bodies and another between L I and L5 with a wedge-shaped body L3 . In both areas neural arches were massivelyinvolved, making the diagnosis of tuberculosis somewhatdoubtful (Morse etal. 1964:531).To this survey we may add another case of a middle-agedmale found in shaft no. 42 of the uninscribed mastaba B nearthe Pyramids of Giza with wedge-shaped vertebrae TIO and Zagreb Paleopathology Symp. 1988 Vertebral tuberculosis in ancient Egypt and Nubia ? 193 T 1 2 and less compressed T 11 . In spite of the expressed diag-nosis of a "chronic rarefaction" leading to "gradual compres-sion of the . . . vertebrae" (Abadir 1953:85), tuberculousorigin of the condition cannot be excluded as well. MUMMIES Notwithstanding the fact that large series of Egyptian mum-mies have been subjected to radiological and other scientificstudies in the two recent decades, cases with vertebral tuber-culosis remain rare. There is the often-quoted hunchbackpriest of the god Amun called Nesperehan, detected among44 well-preserved mummies found by Grebart in 1891(Smith and Ruffer 1910: Smith and Dawson 1924:156,fig. 62; Cave 1939:142). His mummy shows destruction ofthe lower thoracic and upper lumbar vertebrae causing anangular kyphosis and a large abscess cavity in the area of the right psoas muscle.In the most probably natural mummy of a 5-year-old childfrom an intrusive burial ( 1000-400 B.C.) found in the tombof Nebwenenef at Thebes, pulmonary and vertebral tuber-culosis ending with a fatal hemorrhage was described andtuberculous bacilli proved in the vertebral bones (Zimmer-man 1979). Discussion Together with our two cases, 6 iconographic, 30 skeletal, and2 mummy specimens attest with lesser or greater probabilitythe presence of vertebral tuberculosis in ancient Egypt andNubia. Of the skeletal cases, 19 were from Egypt and 13from Nubia with no particular preference for either of the twocountries. Unfortunately it is not possible to guess how manyvertebral columns were examined by anthropologists experi-enced in pathology and what was the incidence of the dis-ease. The accumulated number of cases discloses, however,that it was by no means negligible.Our case no. 1 comes from an isolated Middle Kingdomtomb inserted in the ruins of an Old Kingdom temple atAbusir. No data on the frequency of the disease, therefore,can be given.Our case no. 2 was found in the Christian cemetery atSayala. The total number of identified individuals was 161 . In no other individual of this group could we detect changespointing to tuberculosis. Thus a rough estimate of incidencewould be 0.62% . Because vertebral tuberculosis accounts for1-3.5% of the incidence of tuberculosis in all its forms, thiswould mean that 1 8-62% of people could have been infectedby tuberculosis at Sayala. Together with other unknowncauses this could explain the extremely low mean age atdeath of its Christian population (about 18 years).The scarcity of findings of vertebral tuberculosis in ar-tificially mummified bodies (representing members of thehigh social stratum that could afford costs of mummification) could well reflect social differences in the incidence of tuber-culosis. However, if we consider that some of the skeletalremains could represent disintegrated mummies (as our caseno. 1 and possibly also the remains of the royal son Pa-Ra'messu), there would be 3 cases out of the total of 32belonging to the royal and priestly society. The incidence(9.4%) does not seem to be significantly smaller than thesupposed percentage share of the high stratum in the ancientEgyptian society.In the present state of our knowledge these reflections canbe no more than preliminary. Much research should be per-formed in the future, aiming at establishing reliable data onthe incidence of vertebral tuberculosis, the excellent markerfor studies of tuberculous infection in different periods, re-gions, and social layers. They are especially important forreconstruction of the social history of ancient Egypt andNubia. Literature cited Abadir, F. 1953. Skeleton Found In Shaft No. 42 of the UninscribedMastaba "B." In A.M. Abu-Bakr. ed.. Excavations at Gi:a1949-1950. 85. Cairo: Government Press.Allison, M.J.. D. Mcndoza, and A. Pezzia. 1973. Documentationof a Case of Tuberculosis in Pre-Columbian America. AmericanReview of Respirator,' Diseases, 107:985-991 . Brothwcll. D.R. 1963. Digging Up Bones. London; British Muse-um (Natural History).Baud, M. \97H. LeCaractereduDessinenEgypteAncienne. Paris:Librairie d'Ameriquc et d'Orient.Cave, E.J.E. 1939. The Evidence for the Incidence of 1\jberculosisin Ancient Egypt. British Journal of Tuberculosis. 33:142.Davies, N. de G. 1927. Two Ramesside Tombs at Thebes. Robb dePeysterTytus Memorial Series, vol. 5. New York: MetropolitanMuseum of Art.Derry, D.E. 1938. Pott's Disease in Ancient Egypt. Medical Press.197:1.Fbrmicola, V., Q. Milanesi. and C. Scarsini. 1987. Evidence ofSpinal Tuberculosis at the Beginning of the Riurth MillenniumB.C. from Arcnc Candlde. American Journal of Physical An-thropology. 72:1-6.Ghalioungui, P.. and Z. Dawakhly. 1965. Health and Healing inAncient Egypt. Cairo: Dar Al-Maarcf.Grmek, M.D.I 983. Les Maladies a TAube de la Civilisation Occi-dentate. Paris: Payot.Hanevcid, G.T. 1980. Pott"s Disease before Pott. The NetherlandsJournal of Surgery. 32:2-7.Jonckhecrc. F. 1948. Lc Bossu des Musecs Royaux d'Art et d'HIs-toirc de Bruxcllcs. Chronique d'Egypte. 45-46:24-35.Manchester, K. 1983. The Archaeology of Disease. Bradford,U.K.: University of Bradford Press.Mogenscn. M. 1930. Lii Glyptotheque Ny Carlsherg. La CollectionEgyptlcnne. Copenhagen: Levin and Munksgaard.Morse, D. 1967. Tuberculosis. In D. Brothwcll and AT Sandison.cds. . Diseases in Antiquity. 249-27 1 . Springfield, 111, : Charles CThomas. Zagreb Paleopaiholog\ Svmp t9/l/l 194 ? Eugen Strouhal Morse, D., D.R. Brothwell, and P.J. Ucko. 1964. Tuberculosis inAncient Egypt. The American Review of Respiratory Diseases,90:524-541.Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho-logical Conditions in Human Skeletal Remains. SmithsonianContributions to Anihropulugy. 28. Washington, D.C.: Smithso- nian Institution Press.Pott, P. 1790. Remarks on that Kind of Palsy of the Lower Limbswhich is Frequently Found to Accompany a Curvature of theSpine. The Chirurgical Works of P. Pott, vol. 3, 409-443. Lon-don.Robins, G. 1983. Natural and Canonical Proportions in AncientEgyptians. Gottinger Miszellen. 61:17-25.Smith, G.E. 1927. Report on the Bones Found in the Sarcophagusof PaRa'messu (Tomb 5). In R. Engelbaeh, ed., Gurob, 24.London: British School of Archaeology and Quaritch.Smith, G.E., and W.R. Dawson. 1924. Egyptian Mummies. Lon-don: Allen and Unwin.Smith, G.E., and MA. Ruffer. 1910. Pottsche Krankheit an eineraegyptischen MumieausderZeitder2l Dynastie. InK. Sudhoff, ed., Zur histortschen Biologie der Krankheilserreger, vol. 3, 9-16. Leipzig, GDR.Steinbock, R.T 1976. Paleopathological Diagnosis and Interpre-tation. Springfield, III.: Charles C Thomas.Steindorff. G. 1913. Das Grab des Ti. vol. 2. Leipzig, GDR: J.C.Hinrichs'sche Buchhandlung.Strouhal, E. 1986. Embalming Excerebration in the Middle King-dom. In A.R. David, ed. , Science in Egyptology: Proceedings ofthe Science in Egyptology Symposia, 141-154. Manchester,U.K.: Manchester University Press.Strouhal, E., and J. Jungwirth. 1984. Die anthropologische Unler-suchung der C-Gruppen- und Pan-Graber-Skelette aus Sayala,Aegyptisch-Nubien. Osterreichische Akademie der Wissenschaf-ten, phil.-hist. Klasse, Denkschriften, 176. Band. Vienna: Ver-lag der Oesterreichischen Akademie der Wissenschaften. Thieme, F.P., and W. Schull. 1957. Sex Determination from theSkeleton. Human Biology, 29:242-273.Todd, TW. 1920. Age Change in the Pubic Bone. American Jour-nal of Physical Anthropology. 3:285-334.Trotter, M., and G.C. Gleser. 1952. Estimation of Stature fromLong Bones of American Whites and Negroes. American Journalof Physical Anthropology, 10:463-514.Ulrich-Bochsler, S., E. Schaublin, TB. Zeltner, andG. Glowatzki.1982. Invalidisierende Wirbelsauleverkrummung an einem Skel-ettfund aus dem Fruehmittelalter (7./8. bis Anf.9. Jhr). Ein Falleiner wahrscheinlichen Spondylitis tuberculosa. SchweizerischeMedizinische Wochenschrift, 112:1318-1323.Vandier, J. 1964. Manuel d'Archeologie Egyptienne. Tome IV. BasReliefs et Peintures. Scenes de la Vie Quotidienne. Paris: Picard.Watermann, R. I960. Palaeopathologische Beobachtungen an alt-aegyptischen Skeletten und Mumien. Homo, 1 1:167-179.Zimmerman, M.R, 1977. The Mummies of the Tomb of Neb-wenenef: Paleopathology and Archeology. American ResearchCenter in Egypt, 14:33-36.1979. Pulmonary and Osseous Tuberculosis in an EgyptianMummy. Bulletin of the New York Academy of Medicine. 55:604-608.Zimmerman, M.R.,andM.A. Kelley. \9S2. Atlas ofHuman Paleo-pathology. New York: Praeger. Summary of audience discussion: These two cases each demon- strate a very large diseased area involving 8 to 10 vertebrae. In theabsence of vertebral body destruction a mycotic etiology might beconsidered. These, however, are rare in Egypt and the second casedoes show two foci of vertebral body destruction. The bilateral nature of sacral involvement is unusual . yet cannot be explained as anontuberculous, mechanical abrasion. Zagreb Paleopathology .Symp. 1988 Leprosy Leprosy and tuberculosis in the Byzantinemonasteries of the Judean Desert Joseph Zias In his classic work of 191 1 on biblicalmedicine, the German physician J.Preuss noted that there were nearly asmany books and treatises on the subjectof biblical leprosy as there were on cir-cumcision in the Bible (Preuss 1978).However, despite the plethora of writ-ten information on this ancient diseasewhich, according to literary sources,existed as early as 600 B.C., scant ar-cheological evidence of leprosy existsprior to a.d. 1200. In fact, prior to thepublication of Preuss's encyclopedicwork, there had been only one findfrom the postbiblical period (a.d. 5(X))in Nubia (Smith and Dawson 1924).Even today, despite the intense world-wide activities of archeologists andphysical anthropologists, no indisputa-ble physical evidence of the disease hasbeen found, with the exception of iso-lated instances in the United Kingdom,North Africa, and the cemeteries of me-dieval Danish leprosaria. In Israel,where evidence of man's presence isover one million years old, and wherethousands of skeletal remains havebeen uncovered, evidence of leprosyhas eluded us. In fact, S.G. Brownenoted in 1975 that not a single case hadever been found in ail of the FertileCrescent.In the spring of 1983, excavationswere carried out at the Judean Desertmonastery of Martyrius, which hadbeen founded in the fifth century anddestroyed by the Persians in a.d. 614,never to be rebuilt. Here a commongrave was discovered in an ancientchurch fioor, dated by inscription to Zagreb Paleopathology Symp. 1968 492. The grave contained the skeletalremains of nine men and one woman,four of whom showed bilateral mutilat-ing changes on the hands and feetwhich were originally thought to be as-sociated with leprosy (Figure I ). Sub-sequent study of the material by the au-thor with American and European specialists in paleopathology showedthat our original diagnosis of leprosywas incorrect. Despite the widespreadinvolvement of the small bones of theextremities with numerous lytic de- .rf^ structive foci, the concentric absorp-tion of the phalanges, metatarsal andmetacarpal bones, which is common inleprosy, was absent. Moreover, threeindividuals showed ankylosis of the vertebral column and the sacroiliacjoint, which is not usually associatedwith leprosy. The widespread skeletalinvolvement of the disease with varyingdegrees of architectural destructionsuggests that psoriatic arthritis is thepreferred clinical diagnosis rather thanleprosy as was earlier reported (Zias Figure I. Phalanges of the hand. (Courtesy of Israel Antiquities Authority. TSagiv) 197 198 ? Joseph Zias Figure 2. Hyena feces showing textiles and human bone. (Courtesy of Departmentof Antiquities, Ministry of Education and Culture, State of Israel?T. Sagiv) 1985). Since psoriatic arthritis affectsboth the skeleton and the skin of theindividual, it mimics to a certain extentthose changes usually associated withleprosy, which may have been the rea-son for inclusion in the Byzantine mon- astery. Literary evidence from the Med-iterranean area indicates that the EarlyChurch established hospitals for thecare of those suffering from leprosy asearly as the fourth century a.d. (Avi-Yona 1963). Therefore it seems entirelyplausible that these four individualsmay have been mistaken as sufferingfrom leprosy and sought refuge in thedesert monastery of Saint Martyrius.Following this discovery, we ob-tained permission from the Greek Pa-triarch to survey the few Byzantinemonasteries possessing skeletal collec-tions dating from the Persian massacresof A.D. 614. This survey, however, didprovide evidence of leprosy in the HolyLand during the seventh century and earlier.In the summer of 1983 we were noti-fied of the accidental discovery of amass grave at the Monastery of John the Baptist near the Jordan River where,according to Christian tradition, the "washing of the lepers" took place(Hoade 1981). Most of the grave hadbeen destroyed by a bulldozer; how-ever, we managed to retrieve 34 skel-etons which were dated by ''*C to ap-proximately A.D. 600. Owing to theunique environmental conditions (400meters below sea level, minimal hu-midity and rainfall), preservation wasexcellent. One interesting aspect of thisfind is that some of the burial customs,such as placing seeds from the tree Bal-anites aegyptiaca in the hands of thedeceased, conform to ancient Egyptiantraditions, suggesting that these indi-viduals had traveled for some consider-able distance prior to their deaths.Among the human remains were feces(subsequently identified as those of ahyena) which contained fragments ofhuman hair, bone, and remnants of thesame cloth found in the grave, suggest-ing that those buried here had beenkilled in the Persian massacre of a.d.614 and had been buried only hours ordays later (Figure 2). Anthropological analysis of the skel- etal material showed those specific de-structive and erosive changes known tobe caused by Mycobacterium leprae inthe hands, feet and lower extremities.Evidence of tuberculosis, in the form ofpleural calcification, was also noted inthis collection (Figure 3).The appearance of tuberculosis andleprosy, both of which are rare in theHoly Land, raises important questionsabout this site. Although hospitals werefrequently associated with monas-teries, no literary evidence from thisperiod attests to the existence of a hos-pital at the Monastery of Saint John.However, the high incidence of patho-logical material found here suggeststhat these buried here were seriously ill, perhaps members of a hospital pop- ulation who may have been banished tothe desert. This tradition of banishmentis apparently an ancient one, in that thefirst archeological evidence of leprosycomes from the Dakleh oasis in theEgyptian desert. Here, interred in aSudanese cemetery dated to about 200B.C., were the remains of four Cauca-sian males, all of whom showed stig-mata of leprosy (Dzierzykray-Rogalski1980).Further survey and research in the Ju-dean Desert monasteries, which pre-date the Danish leprosaria by some 600years, should provide an answer to themuch-debated question of which dis-eases in antiquity were included in thegeneric category leprosy. For example,talmudic evidence of the postbiblicaland Byzantine periods suggests that se-vere nasal disfigurement was con-sidered one of the stigmata of leprosy(Rosen 1982); at this site, 2 of the 34skeletons showed nasal abnormalitiescharacteristic of neither tuberculosisnor leprosy. The cotton textiles re-covered from this site may also shedlight on whether those buried here, ap-parently seriously ill and banished tothe desert, had been required to weardistinctive clothing indicative of theirhealth status.Finally, one of the more intriguingmedical questions that may be an-swered by further study of these monas- Atfirfh l*aleopatholof>\ Sytnp. 19HH Leprosy and tuberculosis in Byzantine monasteries of Judea ? 199 i Figure 3. Calcified pleura. (Courtesy of Israel Department of Antiquities andMuseums?T. Sagiv) tic sites is that of the paleoepidemiolo-gy of leprosy and tuberculosis. Since,apart from this find, tuberculosis andleprosy have rarely been found in theHoly Land, these patients may havecome from abroad or may have immi-grated while incubating these diseases.One wonders, therefore, what factorsmay have operated to restrict the dis-eases to these desert communities. Was social and religious separation betweenthe various communities so complete asto protect the members of one com-munity from a disease prevalent in an- other? Did those who traveled great dis-tances do so for spiritual reasons, orhad they been banished from their homecommunities? According to Judaicand Christian literary sources of thatperiod, those suffering from these dis-eases were ostracized. Perhaps theywere welcomed by these desert com-munities, thus explaining the lack ofsuch remains elsewhere in the HolyLand. Further excavations and otherstudies in the monasteries of the JudeanDesert may well provide answers toquestions such as those raised here. Literature cited Avi-Yona, M. 1963. The Bath of the Lepers at Scythopolis. Israel Exploration Jour- nal. 13:325-326.Browne, S. 1975. Some Aspects of the His-tory of Leprosy: The Leprosy of Yester-day. Proceedings of the Royal Society ofMedicine. 68.Dzicrzykray-Rogalski, T. 1980. Paleo-pathology of the Ptolemaic Inhabitants ofDakleh Oasis (Egypt). Journal ofHumanEvolution. 9:71-74.Hoade, E. 1981. Guide to the Holy Land.501-504. Jerusalem: Franciscan Press.Preuss, J. 1978. Biblical and TalmudicMedicine. New York and London: San-hedrin Press.Rosen, Z. 1982. The Healthy and the Dis-eased Nose in the Bible. Proceedings ofthe First International Symposium onMedicine in the Bible. Koroth. 8:79-85.Smith, G.E., and W.R. Dawson. 1924.Egyptian Mummies. London: Allen andUnwin.Zias, J. 1985. Leprosy in the ByzantineMonasteries of the Judean Desert.Koroth. 9:242-248. Summary of audience discussion: Thelesions on the anterior surface of the patella arc considered occupational (monasterymonk) because of their ancient and evenmodem habit of falling to their knees, ris-ing, then kneeling again and continuing thisprocess daily for hours on end. Since, dur-ing kneeling, the patella does not actuallymake contact with ihe ground, but suffers substantial stress during the lowering and raising of the body, the lesions may resultfrom that stress. We also found lice, not so easily in the mummy's hair but very easilyin the hair combs. Zanreh Pateopathoiogy Symp. 1988 Evidence of disease in ancientNear Eastern texts: Leprosy in theEpilogue to the Code of Hammurapi? Debra A. Chase A great deal of caution must be exercised in the discussionof disease in ancient Mesopotamia. In part, this caution isdue to the nature of the available sources which, scatteredover many centuries, are often fragmentary and filled withlexical difficulties. ' It is the duty of the philologist and stu-dent of the culture to interpret texts using etymologies, andliterary and form critical analyses. This textual work is notcomplete, however, without input from the physical and so- cial sciences (Biggs 1969:103). Over a quarter of a centuryago Oppenheim (1962:107) noted that the study of Meso-potamian medicine had been hampered by separation be-tween departments: its interpreters were "either philologistslacking knowledge of medicine, its history, or that of phar-macology, or physicians without adequate linguistic train-ing." It is in the spirit of long-needed interdisciplinarycooperation that I off"er for discussion this text from the Epi-logue to the Code of Hammurapi, which, I believe, presents amore complete picture of the clinical manifestations of lep-rosy than any other text from ancient Mesopotamia proposedto date. 2 Before examination of the passage let me give a briefsynopsis of the use of the term in the translations of textualdata from Mesopotamia. In my study I have encountered atleast four different words that have been translated by "lep-rosy." There is a fairly straightforward philological explana-tion for this: the Akkadian loanword saharsuppu may betraced to Sumerian SAHAR.SUB.A.. literally, "covered withdusf (i.e., dustlike, whitish scales) (Oppenheim 1956:273n.54). Indifferent lexical series 5-4/M/?.5t/S./4. is equa-ted with the terms epqu and gardbu. Thus, saharsuppu =epqu = gardbu. Furthermore, .ra^wrv(//7^M occurs in contextsin which the affliction covers the individual "like a garment"and results in his wandering outside the city walls "like a wildass on the steppe." The combination of excommunicationand "whitish scaly skin"?which was not considered inap-propriate for leprosy until Dr. S.G. Browne (1967:190)pointed out its unsuitability in a reply to J. V. Kinnier Wilson (1966:47-58)?contributed to the translation of the Akka-dian as "leprosy." The fourth term, busdnu, seems to havebeen translated "leprosy" on the basis of association withsymptoms more appropriate to the disease (it atTects themouth, nose, skin); however, other references would militateagainst such a diagnosis. It is necessary to underscore that the passage from theEpilogue is not a medical text. It does not set forward symp-toms for the sake of diagnosis or prescription of medication.Rather, it is a single curse invoking the goddess Ninkarak, inthe context of a series of curses which Hammurapi enjoinsthe gods to bring upon those who would in some way changehis laws. The form ? (1) deity name (2) deity epithet (3)curse? is typical of Near Eastern curses for a period of morethan a millennium. The diction and poetic devices apparentin the curse reveal a subtle literary skill. I would suggest,however, that behind the imagery lies a very specific disease entity that Ninkarak is called upon to inflict. Such a supposi-tion is supported by the fact that the basic nature of the curseremains the same over time. Although the description of thesymptoms is general by modem standards and certainly notpathognomonic, the presence of cutaneous lesions, testiculardamage, and suggestion of neuropathy point to a considera-tion of leprosy as the disease.The text and translation follow:^ 50. ^Ninkarak51. marat Anim52. qabiat53. dumqiya54. ina Ekur55. mursam kabtam56. asakkam lemnam57. simmam marsam58. Sa la ipaSSehu59. asO qerebSu60. la ilammadu 200 Zagreb Paleopathology Symp. 1 988 Leprosy in the Epilogue to the Code of Hammurapi? ? 20160. 202 ? Debra A. Chase "most variegated clinical spectrum" (Arnold and Fasal1973:40). The skin manifestations may be "macules, pa-pules, nodules or all three" (Jopling 1984:20). They are mul-tiple with bilateral symmetrical distribution. The face, arms,buttocks and legs are principally involved. '^The malady is further qualified by the relative clause be-ginning in line 58 in which the reader is told: (1) that theillness does not heal (with the denotation of "calm down." "be appeased") (line 58), (2) that the doctor cannot find outits fundamental nature (qerbiim) (lines 59-60), and (3) that itis not relieved with bandages (denotation of nc'ihu = abate-ment of illness (CAD N/1 147a]; D of /id/jw "to stanch, still,allay" ICADN/1 149a)) (lines 60-61). The verbspwid^M andndhii may suggest inflammation and perhaps pain (as doesthe adjective marsam in line 57). I would suggest that if painis implied the text associates it with the skin lesions. In thiscontext it is significant that, particularly in the reactional states of leprosy, there may be a fairly rapid change in skinlesions. Note especially, in a severe Type 2 reaction, whichoccurs almost exclusively in lepromatous leprosy, the lesionsbecome vesicular or bullous and break down (erythema nec- roticans) (Jopling 1984:72 and plate 19). Fever, nerve pain,periosteal pain, muscle pain, and joint pain may also occur(Jopling 1984:73). The neuritis associated with leprosywould be a source of pain; however, in one study 81% ofpatients gave no significant history of pain or tenderness inaffected nerves (Fritschi 1987:173). Again note that unliketuberculoid leprosy, where pain may be present from the earliest stages of the disease, in lepromatous leprosy, nervedamage usually occurs late.The striking simile in line 63 underscores the victim'shelplessness, the futility of any efforts to overcome the ail-ment: kima nisik mutim Id iimassahul "like the bite of death itcannot be removed.''^ The image is palpable; the simmu.asakku. miirsu is apparent on the offender's arms and legs, aconstant reminderof impending death, specified in lines 66-67: adi napistasu ihellii/ "until his life is extinguished." Line 68: ana etlutisu Uddammam. The verb damdmu heremeans "to moan, mourn." There is some debate over thetranslation oi etlutisu. An etlu is a man, particularly a young,able-bodied man (CAD E 407). The form in line 68 may beinterpreted as the nominative plural "men" and as such, thepassage has been translated "he will complain to his men"(CAD E 409b; see also B 73a, D 60a). Such a translation,however, is ill suited to the context. There is no previousreference to the afflicted one's interactions with others andcertainly no meaningful referent for "his men." In light of thecontext of affliction and general physical degradation, it ispreferable to read etiutu. "virility';''' thus, "may he con-tinually moan about his virility." Such a reading is congruentwith the tangible imagery of the curse and, as the final blow,acutely conveys the humiliation of the progressive debilita-tion. The image here is certainly of physical breakdown; how-ever, the reference may even be more specific and refer totesticular atrophy. "Testicular involvement leading to impo-tence, sterility and gynecomastia is well documented in lep-romatous leprosy" (Pareek and Al-Nozha 1985:49). "* "Vary-ing degrees of testicular atrophy are likely to occur,particularly if the disease is neglected" (Jopling 1984:31). Inthe earlier stages the individual is sexually potent but sterile.Impotence and gynecomastia are later developments. Also inType 2 reaction the testes may become swollen and tenderwith acute epididymo-orchitis (Jopling 1984:73).'''Although not diagnostically conclusive, the symptomsmay be interpreted as representative of lepromatous leprosy.Clearly, a chronic skin disease involving numerous skinlesions? specifically located on the arms and legs? is de-scribed. The severity of the ailment is reinforced by the re-petitive formulation of lines 55-57, the fact that its etiologyis unknown by the medical practitioner (as well as the factthat it is inflicted by the "divine" doctor), and that surfacetreatments are of no avail (Fritschi 1987:173).-'' There is animplication that the disease is progressive in the simile, line63, and more concretely, in the iterative verb form (Uddam-mam Gtn damdmu) "he keeps on moaning (line 69) until hislife is extinguished" which points to a length of time betweenrecognition of the infection and its conclusion.-' The possi-bility of peripheral nerve involvement, common in advancedlepromatous disease, was alluded to previously. Althoughlittle diagnostic emphasis can be placed on asakku in our text, it is intriguing that the malady miqtu. from the root maqdtu "to fall down," is associated with the goddess's persistentsimmu in another text.-- Finally, the reference to the loss of virility (lines 68-69) may be interpreted as the testiculardamage that leads to atrophy characteristic of lepromatousleprosy. End notes 1 . A number of summaries on medicine in ancient Mesopotamia are available: Labat 1953; Oppenheini 1962; Reiner 1964; Biggs1969,1978.2. The most current proposal of which I am aware is that ofKinnier Wilson (1982:354-357) who suggests that in an OldBabylonian omen text published by Kocher and Oppenheim in1957, \\\epusu "white spots." and niuidu perhaps, "nodules." on the aftlicted man be interpreted as dimorphous leprosy. Although Icannot offer another interpretation of the skin marks, it seems topush the data too far to infer leprosy without further descriptive material.3. Codex Hammurabi Epilogus R XXVllI .^-69 (Tafel 29).Tablet and line numbers arc taken from the edition of Borger( 1963).The normalizations and translations of the text are my own.4. See Haussig 1965:78 and Wcidner and von Sodcn 1971:695.5. See. for example, this epithet in the parallel curses: Borger1970 (Kudunm SB kol. IV 5-6). 1967:109 (IV 3); King 1912:7 ii29-31. Zagreb Paleopathology Symp. 1988 Leprosy in the Epilogue to tiie Code of Hammurapi? ? 203 6. RLA 3 695. Note the hymn of Nebuchadnezzar to Ninkarak inwhich Nebuchadnezzar appeals to her as a health goddess? for hisown health and longevity and that of his children and descendants(von Soden and Falkcnstcin 1953:#33).7. See Kudurru (boundary stone) of MeliSihu VII 14-25 (Scheil19(X): 1 10); Kudurru SB 33 IV 5-9 (Borger 1970); King 1912; no. 8IV 16. 1 R 70iv6andp.4l 7 ii 29-31 and p. 79 11 iii 10-13.8. R)r an introduction to the subject see Braunwald et al. 1987;du Vivier 1986; Fitzpatrick et al. 1987; Jopling 1984; Stein et al.1983.9. R)r example, associated with the goddess Gula but with re-gard to the heart: GIG Id pcidu ami lihhisu lifhsiC.') KAR 111 r.8 cited from CAD M/2 226a)/ "May (Gula bring) an illness withoutpity into his heart."10. "A diffuse hypesthesia involving the peripheral portion ofthe extremities is common in advanced leproiiiatous disease"(Braunwald etal. 1987:635). 1 1 . Kudurru SB 33 IV 7 which Borger translates as "unheilbareLahmungC?)" ( 1970; 15). See also Goctze ( 1955; 12) who notes that miqtii, literally "fall." is used of attacks for various sicknesses andsometimes equated with bennu. "epilepsy."12. Here Jopling clarifies that "nerve damage in lepromatousleprosy ... is different from the pathological process in the othertypes of leprosy and is much slower to unfold." While in borderlineleprosy "clinical evidence of nerve damage, whether sensory ormotor, or both, is likely to antedate skin lesions by months or years" ( 1984; 15). Tuberculoid leprosy patients may present with neural ordermal symptoms or both (1984:34).13. Note the alliteration (particularly m. s, s, and k) and theinelusio and wordplay, mursiim-nuirsam.14. The range of meaning of Akkadian simmum has been com-pared to Greek elkos which embraces both notions of wound and ulcer. (Stol 1979:62 n.232. kindly brought to my attention by Pro-fessor W.L. Moran).15. Sec Jopling 1984:rigs. 4.15.18, erythema nodosum lep-rosum in Type 2 reaction-which occurs almost exclusively in lep-romatous leprosy or may be the stage at the patient's presentation(1984:70).16. The image here has several levels; (1) Death is frequentlyanthropomorphized as a maw; consequently, the image would beparticularly vivid for its indigenous readers/hearers. See also inasinnatisu izdb mutumi "from his (the demon's) teeth flows death."(A 704: 16 cited from CAD M/2 318a). (2) The symbolic animal ofGula is the dog. (3) Familiarity with an actual animal bite introducesthe elements of the unexpected and speed?a bite often cannot beanticipated or prevented?thus heightening the sense of anxiety. (4)The physical image; once the flesh has been pierced, although theteeth may be removed, the evidence of the attack cannot?thus, theomnipresent awareness of injury.17. CAD E 41 lb. Von Soden (1965:1 266a) who quotes thispassage under etlutu. defines the word as "Mannheit." Therefore,our form y Symp. 1988 Rheumatoid erosive arthropathy in macerated bone specimens ? 213 Figure 2. Macerated control tibia! table from amputee. Note minimal change (focalcollection of small holes in the lateral plateau (left); x 1 V: TaDLE 1. Summary of morphologic changesobserved on rheumatoid metacarpal heads Frequency (%) DlSShCIlNG MICROSCOPE (6-IOX) Articular surfaceDomeComplete resorption 2/10 (20%)Partial resorption 8/10 (80%)Holes 2/10 (20%)CondyleComplete resorption 7/10 (70%)Partial resorption 3/10 (30%)Holes 3/10 (30%)Eburnation 2/10 (20%)Chondro-osseous junctionVallecular resorption 10/10 (100%)Para-articular boneComplete destruction 4/10 (40%)Holes 6/10 (60%) SCANNING ELECTRON MICROSCOPE (lOOX)Resorption lacunae at sites 10/10 (100%)of calcified tissue destruction TAni P 2. Comparison between macerated tibialplateaus of patients with rheumatoid arthritis (RA)and control subjects Figure 3. Macerated rheumatoid tibial table; x l'/?. 214 ? James C.C. Leisen, Howard Duncan, and J.M. Riddle Figure 4. Articular surface of a rheu-matoid metacarpal head showing aneroding front covered with continuousresorption bays and an adjacent miner-alized surface with prominent chondro-cyte lacunae (volcanoes); x 560. SCANNING ELECTRON MICROSCOPICOBSERVATIONS The articular surface of the maceratedspecimens (both control and rheu-matoid specimens) was covered by nu-merous volcanolike structures. Thesewere identified as mounds of mineralenclosing lacunae which would haveoriginally contained a single or severalchondrocytes (Figure 4).At a higher magnification, manysmall holes were seen perforating thesubchondral plate of both the medialand lateral plateaus of the tibial tablescollected from the controls. Theseholes were concentrated at a submenis- cal location on the medial plateau and ata central location on the lateral plateau.In contrast, various-sized holes pene-trated the subchondral plate coveringthe medial and lateral plateaus of therheumatoid tibial tables. No distinctdistribution pattern of holes was ob-served for the plateaus of the rheu-matoid tibial table. Rather, the holesfrequently were present in both the sub-meniscal and central locations of aplateau. The articular surface of the rheu-matoid specimens also showed focalcollections of continuous resorptionbays, an erosion with a morphology characteristic of osteoclastic activity(Figure 4). DiscussionOur series included metacarpal headsand tibial plateaus removed from con-trol subjects and patients with chronic, classic rheumatoid arthritis. The jointsof the rheumatoid patients were func-tionally impaired and painful to the ex-tent that the joint dysfunction necessi-tated surgery and replacement withprostheses. In this group, the rheu-matoid erosion had characteristic fea-tures which included; (I) partial orcomplete resorption of the articular sur-face, (2) obliteration of the chondro-osseous junction, and (3) minimal para-articular osteophytosis. The remainingbony tissue, regardless of location,contained holes or perforations throughthe surface which often exposed epi-physeal trabecular bone and marrowspace. Although histologic features were variable, the scanning electronmicroscope consistently revealed pa-tches of continuous resorption bays atthe eroded surfaces and lining the chan-nels of many holes.A review of the literature containedonly four published papers (Table 3) inwhich an erosive arthropathy was sug-gested through the examination of drybone (Klepinger 1979: 1 19; Ortner andUtermohle 1981:23; Rogers et al . 1 98 1 : 1668; Thould and Thould 1983:1909).Seven skeletons were examined and sixwere found to show evidence of appen-dicular and axial (Ortner and Uter-mohle 1981: 23) bony defects sugges-tive of erosion. These defects werestudied by visual and radiographic ex-amination. Although the authors sug-gest a variety of disease entities, wefeel that the basic issue of "what is anerosion" needs to be addressed usingradiographs and different microscopicapproaches including light microscopyand scanning electron microscopy as il-lustrated in our study.The peripheral joints of a number oferosive arthropathies such as seronega-tive rheumatoid arthritis and the spon- Zagreb Pulenpathnloiiy S\mp. 19HH Rheumatoid erosive arthropathy in macerated bone specimens 'IIS Table 3. Summary of published studies describing an erosive arthropathy seen in dryarcheological bone Author Site Age ofspecimens Material Rogers et al. 1981 Britain A.D. 1200 Ortner andUtermohle 1981Klepinger 1979 Thould andThould 1983 3 of 400 skeletons: 3 males with erosive disease,possible gout (1), psoriatic arthritis (1),rheumatoid arthritisAlaska >A.D. 1200 1 female skeleton age 30-35, polyarticular erosive diseaseSicily 330-210 B.C. 1 male skeleton with distribution of abnormalitiessuggesting rheumatoid arthritisBritain A.D. 0-400 2 of 416 skeletons: 1 male, 1 female with erosionsinvolving wrist and metacarpals dyloarthropathies have yet to be studiedin this manner. In addition, morpho-logic surveys of patients with early andpresumably less severely disablingrheumatoid arthritis might reveal ero-sive features that would be helpful inestablishing the existence of erosive ar-thropathies in paleopathologic skeletal material.Finally, although the word "erosion"implies a focal defect in bone and/or cartilage, as seen radiographically, thistype of focal change was not a featureof the specimens examined in thisstudy. Rather, the rheumatoid erosionswe observed were more extensive andincluded the sum of the anatomical de-fects noted in the articular surface,chondro-osseous junction, and para- articular bone. It appears that a multi-discipline approach that includes thedistribution of joint lesions, radio-graphic evaluation of affected joints,and a careful morphologic survey of the joints using both light as well as scan-ning electron microscopy may be nec-essary to interrelate findings on modempatients with classic rheumatoid arthri- tis to joint lesions present in ancient skeletal remains. Literature cited Duncan, H., J. Jundt. J. Riddle, W. Pitch-ford, andT. Christopherson. 1987. TibialSubchondral Plate?A Scanning Elec-tron Microscope Study. Journal of Boneand Joint Surgery: 69A: 1 2 1 2- 1 220.Klepinger, L. 1979. Paleopathologic Evi-dence for the Evolution of RheumatoidArthritis. American Journal of PhysicalAnthropology. 50: 1 19-122.Leisen, J., H. Duncan, J. Riddle, and W.Pitchford. 1988. The Erosive Front: ATopographic Study of the Junction be-tween Pannus and the Subchondral Platein the Macerated Rheumatoid MetacarpalHead. Journal of Rheumatology. 15:17- Mitchell, DM., and J.R Fries. 1982. AnAnalysis of the American RheumatismAssociation Criteria for Rheumatoid Ar-thritis. Arthritis and Rheumatism. 25:481-487.Ortner, D.J., and C.J. Utermohle. 1981.Polyarticular Inflammatory Arthritis in aPre-Columbian Skeleton from Kodiak Is-land, Alaska, USA. American Journal ofPhysical Anthropology. 56:23-3 1 . Resnick, D.. andG. Niwayama. 1981. Di-agnosis ofBone and Joint Disorders, vol . 2. Philadelphia: W.B. Saunders.Rogers, J., 1. Watt, and P. Dieppe. 1981.Arthritis in Saxon and Medieval Skel-etons. British Medical Journal. 283:1668-1670.Ropes, M.W., G.A. Bennett. S. Cobb, R.Jacox, and R.A. Jesspar. 1958. Revisionof Diagnostic Criteria for RheumatoidArthritis. Bulletin of Rheumatic Dis-eases. 9:175-176.Thould, A.K., and B.T Thould. 1983. Ar-thritis in Roman Britain. British MedicalJournal, 287:1909-1911 Zagreb Paleopathology Symp. 1988 Paleopathology of rheumatism in paintings Jan Dequeker The pathology and history of rheumatism and especially ofrheumatoid arthritis are still poorly understood. Insight re-garding the pathology may be enhanced through perspectivesprovided by the history of disease. Short (1974), in his re-view of the historical documents and reports published onpaleopathological specimens, was unable to find convincingevidence for rheumatoid arthritis earlier than the 1 7th centuryA.D. prior to Sydenham's description of the disease in 1676.This observation led him and many others to speculate thatrheumatoid arthritis is a recent disease, perhaps reflectingrecent changes in the human environment. Thus the clarifica-tion of the history of rheumatoid conditions in human popula-tions is of considerable anthropological interest.Ankylosing spondylitis and some types of erosive poly- arthritis were present from earliest times (Onner and Uter-mohle 1981). A few examples of what could have been mildrheumatoid arthritis have been discovered, but the prolifera-tive, erosive disorders with spinal involvement (possiblypsoriasis or Reiter's syndrome) seem more common. Havethe rheumatic diseases changed? is rheumatoid arthritis diffi- cult to identify? or is it a relatively recent disease? Becausethe question remains open I have directed my interest inpaleopathology of rheumatism to paintings, which may dis-close soft tissue evidence of diseases of ancient time, whichare poorly seen in skeletal remains (Dequeker 1977). The useof the visual arts, for example paintings, as a tool for paleo-pathology research has advantages and disadvantages whichshould be kept in mind clearly.The advantage is that rheumatic diseases affect primarily soft tissue (synovia, tendons and cartilage) and only sec-ondarily after many months and years of disease can bonelesions be detected. In paintings and sculptures the defor-mities due to soft tissue swelling, tendon contractions, andjoint subluxations, resulting in discomfort and disabilities,can be discerned and detected by an experienced clini-cian.The disadvantage of visual arts is that the artists do notnecessarily make portraits of their subjects and may alteranatomical characteristics according to their "feeling" at thetime of their work. While a visit to a museum may seem toyield a rich trove of medical illustrations, things are notalways what they seem. Diagnostic acumen applied to paint-ings can be misleading if not tempered with a knowledge of216 artistic conventions (as mannerisms) and historical context(Ehdich 1987).Taking into account the above restrictions, 1 have the priv-ilege to study paintings made by famous Flemish medieval artists who lived in the area where I practice my speciality of clinical rheumatology.Paleopathological findings of rheumatism in paintings willnow be reported. The adage that one only sees what oneknows is certainly applicable to this field of research. A large clinical background in rheumatology is necessary to recog-nize early clinical features, and to put them in context tomake a firm diagnosis. Rheumatoid arthritis Perhaps the most convincing evidence of rheumatoid arthritisin paintings is the arthritis of the housemaid of Jacob Jordaens ( 1 593- 1 678) as seen in the painting of Jordaens's own family(Figure 1).In order to convince people inexperienced in this field, Ihave chosen a picture (Figure 2) of a hand of one of myrheumatoid arthritis patients of about the same age, disclos-ing the main features: swelling of the metacarpophalangealjoints, the proximal interphalangeal joints, and the wrist.This example of rheumatoid arthritis is sufficiently demon- strative so that it has been chosen to illustrate the latest,authoritative textbook of rheumatology in Great Britain(Scott 1986).Another yet unpublished but very characteristic hand and wrist deformity of rheumatoid arthritis is one I found recently at the Escorial Museum near Madrid in the painting of ananonymous artist of the Dutch school of the mid 1 5th or early16th century.A number of other deformities resembling features seen inrheumatoid arthritis have been discovered in the painting ofJan Rombauts (ca. I5(X)) "Christ appearing to St. Peter"(Leuven, Stedelijk Museum); in the portrait by Joos (Justus)Van Gent (1430-1475) of Federigo de Montefeltre (Urbino,Ducal Palace); in the drawing by Jan Van Eyck (ca. 141 1) ofJohn IV, Duke of Brabant; and in the painting "The Dona-tors" (Brussels) (1525-1530) by Jan Gossaert, also calledMabuse, showing flexion contraction of the second, foUrth,and fifth finger of the left hand (Figure 3). Zagreb Paleopalhology Symp. IV8S Paleopathology of rheumatism in paintings ? 217 Figure 2. Synovial swelling of proximal inter-phalangeal, metacarpal, and wrist joints in a patientsuflering from rheumatoid arthritis. Figure 1. Jacob Jordaens: The painter's family (de-tail); Madrid, Prado. The maidservant's right handshows swelling of metacarpal and proximal inter-phalangeal joints. Figure 3. Jan Gossaert (Mabuse); The Dona-tors; Brussels, National Museum. Flexion con-tractures of the man's right hand. A few years ago I noticed two other remarkable examplesof rheumatoid deformities of the hand in late Gothic paint-ings: one by M. Van Heemskerck ( 1498-1574) titled "AltarPanels with Donors" (Figure 4) and the Avignon Pieta(? 1470) at the Louvre in Paris, by a Southern French Masterentirely under the influence of the Flemish School ( Figure 5).The left hand of one of the donors and the right hand of St.John show grossly deformed joints with fingers twisted andturned sideways or bent backwards. Zagreb Paleopathology Symp. I9S8 FiGURi: 4. M. van Heemskerck: Altar Panelswith Donors; Vienna, Kunsthistorisch Museum.Rheumatoid deformities of the fingers and atro-phy of the dorsum of the hand. Figure 5. Southern French Master: AvignonPieta; Avignon. Twisted fingers of St. John's right hand turned sideways and bent backward. 218 ? Jan Dequeker Figure 6. St. Blankaart: Front page of book on podagra andgout. The young man sitting in a wheelchair has an ankylosedback and knee joint. Ankylosing spondylitis During my search for rheumatic diseases in visual arts I haveencountered only one example of possible ankylosing spon-dylitis. In the front page of the work of St. Blankaart (1684) "Van het podagra en vliegende jigt" on podagra and gout, ayoung male sits with a stiff back in a wheelchair with an-kylosed knee and possibly ankylosed hip, while another male sits in a chair with a walking stick near a fire (Figure 6). Ofthe other two patients, one lying in bed is being bandagedaround the legs and receiving medicine in a spoon, while theother in the foreground is undergoing cauterizations at hisknee. Although they all seem to suffer from rheumatism, it isonly the one in the wheelchair who can be identified as aprobable case of ankylosing spondylitis. The others could bepolyarticular gout or any other rheumatic disease entity in-volving one or several joints. Figure 7. Jan Van Eyck: The Virgin with the Canon (detail);Bruges, Municipal Museum. Temporal arteritis?polymyal-gia rheumatica. Polymyalgia rheumatica Indirect indications of polymyalgia rheumatica, a rheumaticinflammation characterized by shoulder and hip girdle mus- cle stiffness and often associated with temporal arteritis, areseen in the painting by Jan Van Eyck (ca. 1385-1440) of theHoly Virgin with Canon Van der Paele (Figure 7). The Canonis clearly suffering from temporal arteritis, with scar forma-tion and loss of hair of the eyebrow and in front of the left ear.For the sake of completeness, it should be mentioned that healso has a cellular mole and a sebaceous cyst on the left ear.Historical data on Canon Van der Paele published in theCanadian Medical Association Journal ( Dequeker 1 98 1 ) sup-port my clinical diagnosis of polymyalgia rheumatica. Ac-cording to the minutes of the cathedral chapter, he beganhaving difficulty in attending the morning service in Novem-ber 143 1 . By the time the painting was done ( 1 434), the agingCanon was forced to stay home, first in the morning and laterfor the whole day, because of rheumatic pain with morning stiffness, general weakness and ill health. This illness wasnot fatal, however, and he survived the first symptoms for 12years?a history compatible with the natural course of poly-myalgia rheumatica. Zagreb Palcopaihology Symp I98S Paleopathology of rheumatism in paintings ? 219 FiGURK 8. Patient suffering from biopsy-provedtemporal arteritis and polymyalgia rheumatica. In order to illustrate the great realistic capacity of Jan VanEyck, and the likelihood of our diagnosis, the clinical pictureof a patient with identical features at the temporal region andwhose biopsy showed giant cell arteritis is shown (Figure 8).Recently I discovered that a German dermatologist. Roth(1969), had made the same diagnosis in 1969. Mcige ( 1924)described vascular abnormality in the temporal region in fourpaintings, but did not mention the painting of Jan Van Eyck.The Canon was probably not the only sufferer from thisdisease during these centuries. Signs of temporal arteritis canbe seen in Piero di Cosimo's Portrait of Francesco Gambetti ( 1505), now in the Rijksmuseum. Amsterdam. Osteoarthritis In another painting by Jan Van Eyck, "The Lamb of God" retable (Ghent), 1 found one of the few convincing evidencesof osteoarthritis in paintings. The distal intcrphalangeal jointof the thumb of St. John Baptist shows clearly Hebcrdcnnodes (Figure 9), the overall landmark of generalized os-teoarthritis as shown in a picture of a contemporar>' patient(Figure 10). A similar Heberden-likc (knucklepad-like)swelling around the joints can be seen in two paintingsby Bernardo Strozzi (1581-1644): "The Old Coquette"(Moscow) and "The Lute Player" (Vienna). This prominence at the bending of fingers might be a convention of mannerismas suggested by Ehrlich (1987). Ziturvh Pateopalholo^y Symp. I9HH Figure 9. Jan Van Eyck; The Lamb of God reta-ble (detail); Ghent, St. Bavo Cathedral. Heber-den nodes on the thumb of St. John Baptist. Figure 10. Patient with llcbcrden nodes at the distal intcr-phalangeal joints. 220 ? Jan Dequeker Discussion Since the publication of my first findings in the British Medi- cal Journal in 1977, and more extensively in Organorama in1979, two further papers on rheumatoid arthritis in art havebeen published.Appclboom and associates (1981) described a peculiartendency of Peter Paul Rubens (1577- 1640) to paint appar-ent swelling of the wrists and deformities of the hands, and ithas been suggested that either he or his second wife, HelenaFourment. or both, may have had rheumatoid arthritis. In-deed, biographical information on Rubens suggests that hesuffered from rheumatism. In his abundant correspondence,the term "gout" is used to define the recurrent pains andswellings afllicting his hands and feet.Alarcon-Segovia and associates (1983) pointed out thatthe "Portrait of a Youth," painted in 1483 by the Florentine artist Sandro Botticelli, has features of rheumatoid arthritis inthe hand of the subject, who would be young enough to beconsidered as having juvenile arthritis. This painting has alsobeen discussed by Short (1974) as a possible example of arheumatoid arthritis hand, although he admits that it alsocould be an artistic convention or stylistic trait, since Bot-ticelli's hands often have this appearance. When painting anextended hand Botticelli, like many other painters of theRenaissance, placed both middle fingers together and thesecond and fifth apart, as if to relieve the monotony thefingers would create if all were spread. A bent fifth finger isoften encountered not only in Botticelli's paintings but also inthe paintings of Rogier van der Weyden and many others.In another painting by Botticelli, "The Birth of Venus," 1recently described swelling of the proximal interphalangealjoints and a sausagelike swelling of the left index finger(Dequeker 1984). Is it significant that the fingers of the righthand point in the same direction as the drifting hairlocks?An interesting anecdote is that the model for Venus was awell-known individual, namely the 16-year-old SimonettaVespucci, girlfriend of Giuliano di Piero, brother of Lorenzo il Magnifico. Simonetta died a few years later from tuber-culosis (Alarcon-Segovia 1985). It is obvious that caution is called for in drawing medicalconclusions from paintings and engravings. This is particu-larly the case when the hands are taken as the basis, for handsare often used by painters as a means of expression for feel-ings and sometimes as the hallmark of a particular school ofpainting. For example, it is striking to note that many fingersin the canvases of Rogier van der Weyden show very finelong fingers, often with a clinodactylic deformation of thelittle finger. It is also well known that most of the figures in El Greco'spaintings show a picture of Marfan's syndrome. The abnor- malities described in this article are of a different nature.They are not the consequence of a style, except perhaps forthe hands in the painting by Jan Gossacrt; these could point toan expression of a mannerism typical of this artist. Similar deformations of the hands can be seen in a portrait of awoman in the Rijksmuseum in Amsterdam and in that of theman with the garland of roses in the National Gallery inLondon. Both of these works are ascribed to Jan Gossaert.Probably a rheumatologist sees more in the pictures ofcripples than another doctor or a layman because of theknowledge he has acquired in daily practice. What we do notknow, we do not see. Although none of the deformations andswellings of the joints which have been found constituteirrefutable examples of rheumatoid arthritis, they neverthe-less give grounds for a strong suspicion that polyarthritisoccurred so frequently in the Middle Ages that it must havecaught the attention of the masters, and this at a period inwhich infectious diseases such as leprosy and tuberculosisdominated pathology in every field. Arthritis was recognizedin all sections of the population, among rich and poor, andmen and women alike.Ten out of 24 paintings, described in full elsewhere, inwhich arthritic lesions were recognized, represent donors orwell-known personalities of whom a "portrait" was made(Dequeker 1987). This supports the idea that in fact theseindividuals might have been suffering from rheumatic dis-eases. Almost all of these paintings were in the time of theFlemish realistic school infiuence, introduced by Jan VanEyck. Since scrupulous recording like this of wrinkles, veins, warts, stubble on the chin, and congenital malforma-tions are typical for 15th- 16th century Flemish art, therheumatoid-like hand deformities cannot be ascribed tocarelessness, incompetence, or mannerism of the painters. It is thanks to the realism of the Flemish, Dutch and Italianschools of the late Gothic era that we can recognize thesedeformities. During the Renaissance and the Baroque thefigures were so idealized and perfected that signs of diseaseare seldom recognizable in the works of these periods. Al-though the paintings in those earlier days were generallycommissioned by patrons who also figured in them, thepainters did not always spare their benefactors, as we saw inJan Gossaert's and Van Heemskerck's paintings, and in theportraits of Federico da Montefeltro, Michelangelo, CanonVan der Paele, Jordan's Servant, Gambetti, Aegidius, Eras-mus, and Vespucci.These descriptions and pictures do not, of course, provideany scientific proof that rheumatoid arthritis and associatedsystemic disorders occurred frequently in the Middle Ages.But the argument that rheumatoid arthritis does not occur inold paintings equally does not provide scientific proof for theassertion that rheumatoid arthritis is a recent or modem dis-ease. The main reason why they were not noted historically isthat the mean lifespan was too short for a sufficient number ofcases to develop and be recognized as examples of a specificdisease. Rheumatoid arthritis was rare becau.sc age expecta-tion was low, and potential sufferers died before contractingthe disease. There is already evidence that this is a reason forthe low prevalence of rheumatoid arthritis in underdevelopedcountries. In contrast, ankylosing spondylitis is historically Zxif^reh Paleopathoto^y S\mp I9HS Paleopathology of rheumatism in paintings ? 221 well-documented in human remains because this inflamma-tory rheumatic disease preferentially affects younger people.The discoveries of rheumatic disorders in the paintings anddrawings of the Late Middle Ages described here neverthe-less make the current view (that rheumatoid arthritis is a relatively recent complaint) a topic for discussion. Literature cited Alarcon-S^govia, D. 1985. Botticelli and Arthritis. Arthritis andRhctimatism. 28:6(X).Alarcon-Segovia. D., A. Latfon, and J. Alcocer-Varela. 1983.Probable Depiction of Juvenile Arthritis by Sandro Botticelli.Arthritis and Rheumatism . 26: 1 266- 1 268 . Appelboom. T. , C. dc Boelpaepe, G. Ehrlich, and J. P. Famaey.1981 . Rubens and the Question of Antiquity of Rheumatoid Ar-thritis. Journal o] the American Medical Association, 245:483-486.Dequeker, J. 1977. Arthritis in Flemish Paintings (1400-1700).British Medical Journal. 1 : 1 203- 1 205 . 1979. Rheumatism in the Art of the Late Middle Ages.Organorama, 16:9-19.1981 . Polymyalgia Rheumatica with Temporal Arteritis asPainted by Jan Van Eyck in 1436. Canadian Medical AssociationJournal. 124:1597-1598.1984. Arthritis in the Paintings of Sandro Botticelli. Ar-thritis and Rheumatism. 27: 1 196- 1 197. 1987. Rheumatic Diseases in Visual Arts. In T. Ap-pelboom, cd. , Art, History and Antiquity ofRheumatic Diseases,31-40. Brussels: Elsevier Librico.Ehrlich, G.E. 1987. The Cover. Journal of the American MedicalAssociation, 257:892.Meige, H. 1924. Presse Medicale, 26 April.Ortner, D.J., and C.J. Utcrmohle. 1981. Polyarticular Inflamma-tory Arthritis in a Pre-Columbian Skeleton from Kodiak Island.Alaska, USA. American Journal of Physical Anthropology.56:23-31.Roth, W.G. 1969. Arteriitis temporalis dargestellt an cinemGemalde des Reichsmuseums in Amsterdam. Der Haularzt.20:330-332.Scott, J.T. 1986. Copeman's Textbook of the Rheumatic Diseases, vol. I. 6th edition. New York: Churchill Livingstone.Short, C.L. 1974. The Antiquity of Rheumatoid Arthritis. Arthritisand Rheumatism, 17:193-208. Summary of audience discussion: Attempts to trace the historyof rheumatoid arthritis to periods earlier than a.d. 1650 are frus-trated by the style of painting prior to that date. Differences inpattern and symmetry assist the separation of rheumatoid arthritis inpaintings from psoriasis or Reiter's syndrome to some degree but not infallibly. Zagreb Pateopaihology Symp. 1988 Trauma Trauma and treatment in the British Islesin the Historic Period: A design formultidiscipHnary research Charlotte Roberts The study of disease processes in past populations has had along history stemming from 19th century investigations. The skeletal remains of our ancestors have always attracted atten-tion and interest from scholars and amateurs alike, often witha somewhat startling obsession. Lay attitudes to study ofhuman remains have also varied through time up to the pres-ent day; there is now little room or finances for superficial,unplanned study yielding results insignificant with regard tothe archeology of the population as a whole. In addition,current problems concern the ethical aspects of the scientificstudy of recent, and even more distant, ancestors of indige-nous populations, notably the Aboriginal communities ofAustralia (Webb 1987). Prevention of study of ancestral re-mains and their removal from museums for reburial shouldbe an issue of concern to all paleopathologists. The Paleo-pathology Association is at present heavily involved with this reburial issue (Hart and Ubelaker 1987).Paleopathology has, however, advanced over the years interms of its credibility as a science and its recognition byarcheologists as a valuable tool in reconstructing the past. Itneed hardly be said that the remains of people who livedmany thousands of years ago are the nearest evidence whichanybody can hope to obtain to rebuild a valid picture. Nev-ertheless, the discipline has some way to go before it isrecognized and accepted as a useful tool for reconstruction ofancient societies. At times paleopathological studies, in Brit-ain at least, are criticized as being "unco-ordinated and des-perately undcrstafted; therefore there is little possibility ofconstructive exchange of views between the paleopathologistand archeologist" (Cramp 1983: 19). Obviously this is not thecase for all countries where perhaps funding for research ismore readily available, thereby providing an environmentconducive to this interchange of ideas.Paleopathology is but one aspect of interpreting the struc-ture of past societies and, although contributing significantlyto this aim, it cannot survive alone and in isolation from otherdisciplines in archeology. Alone it provides little construc-tive and interpretable data. Every aspect of archeological Zagreb Paleopaihology Symp. 1988 Studies can contribute .something to an understanding of thecomplexities of the lives of peoples in antiquity. As Arnold said (1986:38), "Specialists must continue with their re-search; none need, nor has any right, to believe that theirspecialization is superior to any other; each must feed theirdata, observed patterns and generalizations to those who seekto take a more generalized overview of past human behavior,an overview which must incorporate all types of evidence."All experts in their own fields must collaborate to create anaccurate interpretation of the society they are studying. Oneshould try to use even fragmentary data, because, as Biseland Angel said (1985:198): "It is by consideration of allfactors together that more reliable conclusions can bedrawn." Reece (1982:348) clearly is in agreement with thisstatement when he bemoans the lack of integration of allaspects of cemetery studies: "I have yet to find a report whichintegrates all these facts, and it is the separation of bonesfrom bodies, and bodies from cemeteries and finds, thatcauses my dis-ease." Reece found a general failure to inte-grate human bone reports from Roman cemeteries in Britainwith the cemetery report as a whole. He emphasizes(1977:355) "the incredible stupidity of digging a cemeteryand then classing the major source of information as an op-tional appendix."Attempts at using integrated multidisciplinary evidence toreproduce particular aspects of a society, such as diet andchanges in economy, have been successful in America(Gilbert and Mieike 1985; Cohen and Armclagos 1984) andanthropologists have advocated a close working relationshipbetween them and archeologists (Osborne 1969). preferablyin departments employing workers in both disciplines. Inter-pretation and understanding should be the ultimate aim ofstudying all types of archeological and related data.The following paper shows an attempt to use many differ-ent types of evidence to reconstruct how well or how badlypast peoples managed injuries to the long bones and skull.Paleopathology by its very nature relics on diagnosis basedon modem clinical medical method, and interpretation of225 226 ? Charlotte Roberts data in the ideal world has to be done with reference to clinical texts and experience. The diagnosis and interpreta-tion of trauma is. of necessity, heavily reliant on radiographicanalysis, and this particular research is based very mucharound this theme. Correlation with other classes of evidenceis without doubt essential to the potential success of interpre-tation of the data. History of trauma studies Trauma can be defined as any bodily injury or wound andmay affect the bone and/or soft tissues of the body. Fracturescan be defined as the result of any traumatic event whichleads to a complete or partial break in the continuity of bone.Trauma is a common affliction of modem lifestyles, as it wasin the past, and people do, and did, react to it in a variety ofways. Trauma is painful, visual and debilitating, and Withers(I960: 1 ) perhaps summarizes these thoughts on the implica-tions of trauma: "In times of stress, pain or of sorrow, thehuman being will go to any length to try and find help." Inhuman skeletal studies it is difficult to be precise in aspectssuch as complications of particular fractures but it is essentialto be aware of these potential complexities. Applied anatom-ical studies in paleopathology should be one of the first con-siderations.Data on fractures for paleopathologists in past years hasappeared in four forms: (1) as part of a bone report (i.e.,incidence of fractures), (2) as a specific study on fracturepatterns in particular populations, (3) as a study of fracturesof a specific bone, and (4) as part of a treatise on paleo-pathology.The quality and quantity of analysis and interpretation oftrauma is determined by the worker's preferences or the arch-eologist's requirements for a bone report. In many casesbasic descriptions of skeletons present is all that is providedor required. In other cases a more detailed report is appropri- ate. All human skeletal reports describe any traumatic lesionsobserved in the populations (e.g.. Wells 1982:161). Someliterature has also appeared which exclusively describes trau-ma in a specific population (e.g.. Zivanovic 1984; Lovejoyand Heiple 1981; Jurmain this volume). In Britain, occasion- al publications specifically on ancient skeletal trauma havealso appeared (see Manchester and Elmhirst 1 980; Manches-ter 1978; Courville 1965) but these have tended to concen-trate on the wound appearance and the potential weaponrycausing the injury.Case studies of unusual pathological lesions (e.g. , Roberts1987) have been and always will be prolific in paleopathol-ogy, as the method is an efficient way of transmitting infor-mation. Studies concerning trauma have also appeared in thistype of literature. Although useful, there is little possibilityfor synthetic study from isolated reports. Several books deal with paleopathology generally (Ben-nike 1985; Ortnerand Putschar 1981). Obviously, these vol-umes discuss trauma, but the very widespread nature of pal-eopathology precludes expansion of data on trauma into amore valid interpretation for human skeletal studies.In modem clinical literature the contributions to trau-matology are prolific and make comparison between modemand ancient trauma possible. Incidence rates of fractures, sex ratios and age ranges, causes, types of treatment, healing,and complications are all well documented. This providesan, as yet, unrealized potential for comparing ancient frac-tures with modem data. Present study The potential for the study of trauma in populations has notyet been fully appreciated. While trauma in osteoarcheologi- cal analysis is universally reported, there is often little expan-sion of the basic data. Fortunately, in Britain extensivedocumentary research and archeological excavation and in-terpretation has led to a considerable archive of informationwhich can be utilized to supplement human skeletal observa-tions not only in trauma but in many other paleopathological studies. Obviously, limitations have to be realized, and col-laboration between the skeletal specialist and specialists con-versant with all types of evidence being used is essential. AsDaniels ( 1978:28) stated, " Archaeology has become a sub-ject too complex for the simple polymath to handle."Considerable thought about trauma studies, developed bythe author in 1983. led to a proposal for research. The hy-pothesis to be tested was as follows: Populations were capa-ble of and had the technology and intelligence to treat traumain antiquity.To test this hypothesis the research design en-compasses: ( 1 ) study of dry bone evidence for trauma in theform of fractures of long bones (humerus, radius, ulna,femur, tibia and fibula) and the skull, using macroscopicobservation and radiography; (2) correlation of this data withother classes of evidence to illuminate the knowledge oftreatments and technology used in each time period from theRoman to late and post-Medieval eras.The rationale for the selective study of long bone and skullfractures is that injury to these areas of the body would bemore detrimental to the individual's well being than, forexample, a fracture of the rib, clavicle, or a peripheral bone.Trauma is extremely devastating not only skeletally but gen- erally to the body system.The main sources of evidence used were human skeletalremains, modern clinical comparative data, secondary docu-mentary sources, ethnographical studies, art forms, and ar-cheological data such as surgical artifacts, environmentaldata indicating hygiene, living conditions and diet relevant tohealing of fractures. Zagreb Paleopathology Symp. 1988 Trauma and treatment in the British Isles in the Historic Period ? 227 LIMITATIONS OF THE EVIDENCE There arc a number of significant restraints on the data forthese classes of evidence but the main areas become readilyapparent. They are brietly reviewed here and discussed inmore detail later in the paper. FRAGMENTARY SKELETONS. Investigation of a large numberof cemetery sites from different areas of the British Isles wasconsidered essential to obtain a valid picture of trauma. How-ever, the number of cemetery sites examined precluded es-timation of an absolute incidence of particular fractures. Datawas not available for counts of individual bones for most ofthe sites. First, it was not feasible in terms of time to under-take this work as part of the research, and second, it was feltthat it was not a particularly relevant area of study for thesubject matter of this project. AGE AT FRACTURE. Agc-spccific incidence rates of fractureshave been quoted by many workers in human skeletal reportsbut, in fact, these data mean little. Fractures evident on skel-etons could have occurred at any time prior to death. There iscurrently no method of estimating at what age a fractureoccurred in ancient skeletal material beyond about one year after the injury, unless the fracture occurred close to deathand there is extant evidence of very new bone formation orprimary callus. SUBADULT FRACTURES. Grccnstick fractures occurring inchildhood, even in modem populations, may heal and re-model so well that the original fracture line may not be visibleon x-ray. In ancient populations these fractures may not berecognized even macroscopically. RECENT ANTEMORTEM FRACTURES. Fracturcs Occurringshortly before death may be difficult to distinguish frompostmortem fractures ofbone due to burial and/or excavation. STRESS FRACTURES. Stress fractures will not be identifiedunless all the bones of every skeleton are x-rayed. Even so,many will not be evident on an x-ray. SKULL INJURIES AND BRAIN DAMAGE. Consideration of skullinjuries and their potentially associated brain damage can beproblematical. Some types of head injuries induce con-trecoup damage to the brain while others produce directdamage to the subjacent brain. In addition, complications ofskull injury can be complex and multifactorial. TREPANATION. In somc cascs it is difficult to distinguishbetween postmortem holes in the skull and trepanation and,of those trepanations which have no injury associated withthem, one can only speculate on the raison d'etre. ART AND LITERATURE. Representations of past events in anor literature are inevitably controlled by the author's or art-ist's preferences or interpretation, and their validity as evi-dence of disease or therapy is questionable. MODERN PRIMITIVE SOCIETIES. These populations are sepa- rated in both space and time from ancient British societies butthey may be comparable in terms of their disease conceptsand treatment. ARCHEOLOGiCAL EVIDENCE. Interpretation of archcologicalevidence is controlled by the remains studied. All materialremains are a sample of what was actually deposited in theground and many factors determine their survival and ex-cavation. For example, splints u.sed for fractures were proba-bly constructed from biodegradable material, such as wood,and either do not survive to be excavated due to site-specific soil conditions or were not buried with the skeleton. Mostfractures seen by the paleopathologist are healed and there-fore do not need to remain splinted at death and burial.Notwithstanding the limitations present in all forms ofarchcological research, the potential for the study of trauma-tic lesions in human skeletal remains is considerable.This paper does not present a definitive analysis of resultsbecause the research program is still in progress. This report,which is therefore interim, seeks to outline the sources ofevidence used and the rationale thereof, the observationalmethodology and the criteria of analysis of those sources. METHOD SKELETAL EVIDENCE The skeletal evidence for bone fractures is extensive asshown by previous analysis of human remains. This evidenceoccurs in varying incidence throughout different populationsand periods of time, although there is, as yet, little dataavailable on fracture incidence in the past.Location of skeletons in museums, archeology and an-thropology departments in universities, and in archcological units was often difficult. A total of approximately 30,000individuals were located in institutions around Britain. Ap-proximately 6000 individuals have been examined to date.An attempt was made to look at equal numbers of skeletonsfrom the time periods of interest. Table 1 lists the cemeterypopulations studied (Figure 1). The Roman, Anglo-Saxon,Medieval, and post-Medieval periods were chosen for studybecause of the availability of skeletal material and contem-porary documentary, art, and archcological evidence forthese eras. The availability and numbers of prehistoric re-mains in Britain would not give a representative study, andadditional types of evidence of prehistoric context are notalways available. Zagreb Paleopalholofiy Symp. 1988 228 ? Charlotte Roberts Table 1. Total numbers of skeletons examinedRoman Anglo-Saxon Medieval Castle Street, Chester Trauma and treatment in the British Isles in the Historic Period ? 229 DISTRIBUTION OFCEMETERY SITESEXAMINED Figure I. Distribution ofcemetery sites examined. Note thatsome areas represent more than one site. Burial conditions obviously determined how complete thecollections were. On some sites the soil pH was so low thatmuch of the skeleton was eroded and some bones were notpresent for examination. This, among other factors, deter-mined the number of traumatic features observed. CLINICAL DATA The study of trauma in past populations is, of necessity,linked to diagnostic criteria in modem populations. For-tunately, in contrast to ancient studies of populations, mod-em studies of trauma are abundant in the literature. However,clinicians have far more data to study including, in manycases, a cooperative and talkative patient and clinical noteson which to base diagnosis and treatment. The clinician alsohas modem diagnostic t(X)ls and continuing development ofnew methods and drug therapy to aid treatment.In ancient populations the researcher is limited to a study,with whatever means available, of the dry bone evidence fortrauma and treatment. Use of only one source of evidence for Zagreb Paleiipalholofiy S\mp t9ftS reconstructing particular aspects of society has many inher-ent limitations, not least a biased picture.The use ofmodem clinical data provides the opportunity tointerpret the ancient material with a greater degree of accura-cy than would otherwise be possible without it. Modem trau-ma studies appear in five fomis: { 1 ) papers on fracture pat-tems in populations, e.g., Fife and Barancik 1985; (2)fractures of specific bones, e.g., Einarsson 1958; (3) frac-tures in specific age groups, e.g., children, Sharrard 1979;(4) complete chapters in clinical textbooks e.g. Watson-Jones1976; (5) specific features of fractures, e.g., Watson-Jonesand Coltart 1982.Studies of fracture pattems in modem populations are in-valuable for workers in the field of paleopathology. This isparticularly relevant for the subject of etiology. The differenttypes of fractures observed in modem populations are usuallycorrelated with specific forces acting on the bone. For exam-ple, an oblique fracture is usually caused by an indirect force.In some cases an occupational causation may be postulated(see Merbs 1983).Modem studies of fractures of specific bones are usuallyconcemed with incidence, causes (by age and sex), healingand treatment, which are all subject areas comparable toancient skeletal material. Particularly relevant is the com-parison of treatment and healing between ancient and modempopulations; were ancient populations producing good re- sults from their fracture treatments when compared to mod-em healing and treatment?The modem literature abounds with information on typesof fracture (cranial and postcranial), causes, healing, treat-ment and complications. Reference to this data is essential tothe understanding of ancient trauma and treatment.However, despite being invaluable, modem clinical datahas some limitations. Forces producing fractures have re-mained the same but their actual mode of production hasaltered with changing technology. The literature is filled withdata on fractures caused by high-impact traffic accidents andthose caused by other modem technology. These data are notrelevant to the paleopathology of trauma. Data on healing ofmodem fractures are influenced by modem drug therapy,particularly antibiotics, and by modem methods of fracturemanagement such as plates, pins, screws, and bone grafts.The age at which the fracture occurred and the sex of thepatient are known in modem cases of fracture. In paleo-pathology these details arc often not definitely detemiinable.The age at which the fracture occurred is problematical butwould indeed have had an effect on fracture healing. Manyother factors must be borne in mind when interpreting thehealing of palcopathological fractures using modern data.Environment, hygiene, living conditions and diet in the de-veloped world should be beneficial for efficient healing andshould therefore influence healing times and the propensityto infection. In addition, blood vessel and nerve injuriesassociated with fractures in the palcopathological evidencewould have significantly affected how quickly a fracture 230 ? Charlotte Roberts healed. In modem contexts surgical repair of vascular andneurological lesions would be available and thereby lessenhealing time. SECONDARY DOCUMENTARY SOURCES AND ART FORMS In the process of using human skeletal remains from theRoman to late and post-Medieval periods, the availability ofdocumentary sources and art forms becomes apparent, al-though many such sources were produced abroad and thetexts translated into English. Sources of documentary and artevidence available for use are books by specific authors (in-cludes herbals; see Rohde 1922); medical manuscripts (e.g.,Dawson 1934); illustrations on coins, pottery vessels andfrescoes and in manuscripts; and sculpture.All these sources are secondary to the primary source. The validity of evidence is determined by the author's or artist's "clinical acumen" and by modern interpretation of docu-ments and artforms. Although these sources of evidence areinvaluable for workers in this field, they should be used withcaution.Authors may use words which have changed in meaningthrough time , or the words may describe something of whichthe people in the past did not know the meaning (Marwick1970:4). Some words used in everyday speech may actuallybe confusing when used in a historical context. Translation ofcertain words from one language to another (e.g., Latin toEnglish) may prove dift'icult if there is not an exact equivalentof the word. Historical writing is interpretative and theremust therefore be a subjective element therein. All authorsand artists working in each period portray history influencedby their own interests. Some historians may pay particularattention to certain areas of interest and ignore others. Asprimary sources are often fragmentary, there is a tendency forconflicting conclusions (Marwick 1970:23). The very natureof the raw material, however, dictates the historian's functionto convert it into the finished product by whatever means.Illustration and sculpture of events in the past also reflectthe prevailing and stylistic conventions at the time of produc-tion. Before the advent of television, photography, film andprinting the only way to convey information was to make apicture of it. The artist or sculptor may produce what he/shewishes to portray to observers and not the true factual recordof the event in question. Nevertheless, this source of evidenceis invaluable for the study of the treatment of trauma inantiquity and, as Herriinger ( 1970:7) said, "A good illustra-tion is often better than a thousand words."Documentary and art evidence for treatment in the past isabundant in the sources for each period under consideration.Its abundance, however, docs vary; illustrations and docu-mentary evidence are, of course, more prominent in the Me-dieval and later periods rather than in earlier times. However,much of the evidence in the later periods has clear connec-tions with earlier Greco-Roman medicine and surgery as displayed in early texts. A large quantity of relevant docu-mentary material was transferred to Britain from the east bytravelers and invaders of the island. However, before textscame to Britain they were mixed with ancient Roman re-ligion, Mediterranean folk elements, and magico-religiousideas from the Far East (Grattan and Singer 1952). Texts weretranslated into English from Latin, mainly by monasticscribes, and made more accessible to a wider cross-section of society.In the Roman period much of the medical and surgicalknowledge was gained from earlier Greek practice and tradi-tion. By the sixth century B.C. the Greeks had contact withEgypt and had gained much valuable information. Medicaldogma, especially in the Anglo-Saxon period, was modifiedby Celtic elements, southern Italian influences, and Anglo-Saxon tradition. In the Medieval period a new influencecame from the Arabic medical world, works which were thentranslated into Latin.The synthesis of different sources of information seems tohave been a mixture of ideas from Britain and abroad. Muchof this medical and surgical evidence can be traced to itsoriginal source and therefore differences between primaryand secondary sources can be noted. It is necessary to take anoverall view of the evidence to assess any inconsistencieswhich may arise. Nevertheless, there is much value in usingthese sources of evidence for reconstructing past treatment oftrauma.The use of documentary and art evidence in the context ofthis research is undoubtedly hazardous. No one person hascomprehensive knowledge of all the subject areas whichneed to be covered. A multidisciplinary approach to traumaand treatment is therefore the basis of the current research. Inthat respect, there is a need to rely on experts in other fields ofstudy such as art and documentary research, to supply evi-dence to supplement and integrate with the rest of the data.While the limitations are clear and realized, the evidence willbe used. ETHNOGRAPHICAL DATA The use of data from modem primitive societies on medicaland surgical treatment of trauma is a further method of recon- structing this complex feature of past societies. Direct evi-dence of medicine and surgery in early man is meager, al-though secondary sources are abundant. It is reasonable toassume that modern primitive societies have retained thecharacteristics of their prehistoric predecessors in the field ofmedicine (Ackerknecht 1982:10).Although modem primitive societies are removed fromancient populations under study in terms of time and space,they are probably the most comparable equivalent. However,use of this type of data has received some criticism in thepast. Scholars believed that information from modem primi-tive peoples was too different to use to explain archeological Zagreb Paleopathology Symp. 1988 Trauma and treatment in the British Isles in the Historic Period ? 231 data. However, by the late l%()s. in Britain at least, moreinterest was shown in the use of ethnoarcheologicai evi-dence. The problem with studying archeology is the loss ofhuman character in all the remains observed (Schwarz1978:vii). It is by studying societies of similar characteristicsin existence today that a more humanistic and relevant inter-pretation of past behavior can emerge.The problems encountered in the use of ethnographicalevidence are apparent. There is a bias of study of modernprimitive societies toward hunter-gatherers (Kramer 1979:3)but this is perhaps a necessary and useful act before these .societies are encompassed into a more settled way of life withmodem ideas and technology. The periods of time beingstudied in this particular research deal with people whoseeconomy is not hunter-gathering, so care in the comparisonand interpretation therefrom of these diverse societies is real-ized.Ethnographical studies to date have also concentrated oncertain areas of the world, such as Africa, South America,and Alaska (e.g., Carroll 1972). Although these are areaswhere many societies remain uninfluenced by western ideas,such concentration leads to a bias in data availability. Prob-lems also arise when workers try to use only one society toexplain their archeological data. A wide variety of eth-nographical evidence should be utilized at all times.Past societies in Britain, as we have seen, are very distantfrom the surviving modern primitive societies. For example,British researchers could not justifiably use analogies be-tween our contemporary industrialized society and the pre-historic and early historic past. But, analogs for past societiesin Britain are provided for by historical documents whichreduce the time and space elements. Even withstanding theselimitations, use of this type of data should be consideredbeneficial rather than being rejected. ARCHEOLOGICAL DATA Three types of archeological data are relevant to the research: artifactuai, structural, and environmental (Table 3). The in-formation which can be derived from these data is extensivebut can particularly reflect on relevant aspects of past so- cieties in relalit)n to the natural process of fracture healing,and the therapeutic management thereof. The environment inwhich individuals were living (both macro and microscopic),climate, hygiene, diet (including food available and foodpreparation), medicinal plants available, and clothing are allrelevant to the healing process.The availability of this data in Britain is variable. Archeo-logical studies, until recently, have tended to concentrate onthe artifactuai and structural aspects of research activities,primarily because these classes of data were the most abun-dant. It iscommonly accepted that pottery is"oneof the mostcommonly analyzed and useful kinds of artifacts available toarchcologists" (Sharer and Ashmore 1979:306). As methods Table 3. Potential data sets for three types ofarcheological data Examples 232 ? Charlotte Roberts identification and interpretation of environmental evidencesuch as seeds, insects and animal bones has helped to extendarcheological interpretation beyond the pottery stage. Re-searchers no longer end their studies at "what kind of potterydid they have" but can deduce "how people lived." Environ-mental archeology "enables archeologists to move awayfrom examining the sterile remnants of ancient lives andenvisage the communities as they actually lived" (Shackley1985:13). Studying one piece of evidence is no longer ac-cepted as the sole basis for archeological research.The study of archeological data in association with thepaleopathological evidence is essential for an understandingof the treatment and healing of fractures. Environment, in allits facets, and hygiene will affect how well and quickly afracture heals.In Britain, in general terms, archeological data is in abun-dance but there is often a bias in favor of particular periods oftime (often merely because of the abundance of evidenceavailable and of archeologists to deal with it) or regions ofBritain. There is especially a tendency in environmentalstudies to produce detailed syntheses on the environmentalconditions of one structure (see Kenward et al. 1986; Grieg1981 ). These studies are inevitable but useful. Disregardingfinancial constraints, however, these analyses are very labor-consuming. It will be some years before more regional stud-ies of environmental archeology will be available for use insuch archeological research as paleopathology. In the case ofenvironmental archeology at York, the process of analyzingorganic remains is ongoing in order to extend knowledge ofthe archaic environment of York.The study of trauma and treatment in antiquity has bynecessity generated many avenues of research to follow. Onemust consult many areas of evidence to gain an accuratepicture of how well cranial and postcranial fractures weretreated and how well they healed. This research encompassesthe skeletal evidence of fractures and the therapeutic mea-sures of reduction, splinting and trepanation. But it alsocovers many other subject areas: concepts of disease andtreatment, anesthesia, diagnostic procedures, anatomicalknowledge, dressings, surgical instruments and herbal reme-dies, blood letting and hemostasis, complications of frac-tures, hospitals and personnel. The Roman to late and post-Medieval [periods were interesting eras and the wealth ofevidence spanning 1600 years will provide abundant data forthis research. Observational methods RECORDING OF LONG BONE AND SKULL FRACTURES:MACROSCOPIC Consultation of modem clinical data on fractures was neces-sary to compile a recording form adequate to describe the nature of the fracture with reference to modem accounts offractures. Recording forms were developed for both longbone and skull fractures.Cemetery site, period of time (Roman, Anglo-Saxon andMedieval), location of bone, age and sex were recorded asbasic data. The bone or anatomical part affected and side ofbody were noted so that quick reference could be made.Fracture position on long bones was recorded in terms ofproximal, mid or distal third of the bone shaft. Fracturesoccurting proximally or distally to these three levels weredescribed with reference to anatomical points on the bone(Warwick and Williams 1973). The level of fracture on thebone has important implications for particular neural andvascular complications; for example, healing of a fracture tothe distal third of a tibia may be delayed due to a disruption inthe blood supply to the distal fragment and a fracture to themidshaft of the humems may lead to radial nerve palsy. The radial nerve is close to the bone at this point and is thereforevery vulnerable (Klenerman 1966). The effect of continuous radial nerve palsy would be paralysis of the extensor musclesof the wrist, thumb and fingers causing wrist drop.The type of fracture an individual sustains will give anindication of the type of force acting on the bone to producethe break. This feature can have implications for(1) interpreting occupation (e.g., Merbs 1983), warfare(e.g., Manchester and Elmhirst 1980), or domestic acci-dents;(2) determining how quickly the fracture healed. For ex-ample, oblique or spiral fractures are more stable than trans-verse fractures. In addition, some types of fractures are, inmodem populations, correlated with particular types ofaccidents?a Colles fracture of the distal end of the radius,for example, which occurs when a person, particularly anelderly woman with osteoporosis, falls on an outstretchedhand;(3) identifying potential complications of injuries to the skull; for example, a blade injury and depressed fractureproduce different types of brain injury. Different areas of the skull produce contrasting complications.To record healing of the fracture, a general assessment wasmade of how well the bone had healed, taking into accountmany different features identifiable at the fracture site: SHORTENING. By Comparison with the opposite leg or arm,the degree of loss of length was assessed (Figure 2). Thisgave an indication of how well or how badly the fracture wasreduced and/or splinted in the right position. INFECTION . Evidence of an infective process was defined bynew bone growth and/or pitting of the bone surface aroundthe fractured site with or without an associated osteomyeliticlesion displayed as a sinus on the bone surface (Figure 3).Presence or absence of infection gives an indication of the Zafireb Paleopathology Symp. 1988 Trauma and treatment in the British Isles in the Historic Period ? 233 Figure 2. Oblique fracture to distal left tibia of an Anglo-Saxon individual (8th century a.d.) from Raunds, North-amptonshire. Healing has led to shortened affected limb. Figure 3. Radiograph of a Roman (4th century a.d.) indi-vidual from Baldock. Hertfordshire, showing bilateral tibialfractures and sinus in right tibia. environment in which the person was living and the type offracture (simple or compound). DEFORMITY. Rotational or linear deformity was recorded aspresent or absent by comparing with a normal bone. Moredetailed analyses of deformity could be measured on theradiograph (see below). The presence of a deformity in thefracture once healed may suggest that the fracture was nottreated by reduction and splinting. However, the additionalcomplication of fractures of different parts of the body beingharder to treat needs to be taken into account here. OSTEOARTHROSIS. Degenerative change on joint surfaces oflong bones sustaining fractures usually (Kcurs in reaction to stresses placed on the joint caused by deformity of the boneon healing. Again, the presence or absence of this featurewas recorded. In addition, the factor of age was also borne inmind. ALIGNMENT. The alignment of the fractured bone, oncehealed, was recorded to indicate how efficiently the fracturewas reduced and splinted. Additional factors are as outlinedunder deformity.Fractures to the skull were recorded on a form modifiedfrom that used for long bone fractures. The bone affected andfracture position were noted both on the record sheet and in adiagram. Two types of head injury arc commonly identifiedin human remains: a blunt head injury causing a depressedfracture with or without comminution, or a sharp injurycaused by a blade or other sharp object (Figures 4,5).Evidence of healing was noted if the wound appeared tohave rounded and remodeled edges and the presence or ab-sence of endocranial involvement was recorded. This latterfeature would have had severe implications for brain integ- rity. Infection, in the form of periostitic pitting of the bonesurface around the fracture site, was documented. The pres-ence of an infection of a compound or open skull fracture Zaffreh Paleopathology Symp. 1988 234 ? Charlotte Roberts Figure 4. Depressed skull fracture to right parietal bone of a Romanindividual from Hyde Street cemetery site, Winchester. Hampshire. Figure 5. Unhealed blade injury to left parietalbone of an Anglo-Saxon individual from Pewsey,Wiltshire. Figure 6. Healed trepanation associ-ated with a blade injury to right side of skull of a Roman individual from Ciren- cester. would present an opportunity for bacteria to enter the cranialcavity and cause endocranial infection, either abscess ormeningitis.Both long bone and skull fracture forms had a section forcommenting on possible treatment of the fracture. Manyrecorded features of long bone fractures are related to treat-ment, as has been seen, but only by assessing the totality ofthese features could comments be made regarding treatment. Head injuries in the past were sometimes treated by trepana-tion or surgical removal of a piece of bone from the skull. Insome cases there is evidence of a wound to the skull associ-ated with a trepanation (Figure 6). Features of the trepanationwere also recorded?operative site. type, shape and size(length, breadth, depth, internally and externally) of trepana-tion, presence of healing and any indication of infectionpresent. Zagreb Paleopathology Symp. I9HH Trauma and treatment in the British Isles in the Historic Period ? 235 In all individuals, the presence or absence of cribra or-bitalia, porotic hyperostosis, and dental enamel hypoplasiawas recorded to indicate the health status of the individual(Goodman et al. 1984). These features were important interms of healing of the fracture. Fractures might heal slowlyor not at all in an individual who has a poor diet, living inconditions unfavorable for healing to take place. These stressindicators were also noted in the individuals in the cemetery as a whole to compare the general health status of the popula-tion with that of the afl'ected individual. RFXORDING OF LONG BONE FRACTURES: RADIOGRAPHICBy necessity, the evaluation of trauma in ancient populationsis heavily reliant on the use of radiography: macroscopicevidence alone is insufficient to give the information pal-eopathologists should seek. Radiography is perhaps one ofthe few nondestructive informative tools the paleopatholo-gist has. In Britain facilities for radiography are abundant butmany workers in the field of human remains either do nothave the resources to produce many x-rays or do not haveaccess to a machine or friendly radiographer. In order toadequately record the fractures observed in this research itwas necessary to ensure the availability of an x-ray machineand film.Treatment of trauma in past populations was not aided byradiography, which we use today to, first, diagnose whether afracture was present and, second, to assess the relationship ofthe fracture fragments within the limb affected pre-, during,and post-treatment. Today the availability of such modemtechnology allows the paleopathological researcher to x-rayfractures at the stage where the break has, in most circums-tances, already healed.Following examination and recording of the long bonefractures in the data set, each one was x-rayed in standardclinical views, anteroposteriorly and mediolaterally. Theseare the minimum views which should be taken of any patho-logical bone because one projection may be insufficient toassess the abnormality. It was essential that these basic views were adhered to sothat comparison with modem x-rays would be feasible; thiswas a later stage of the project. The radiographic work wasdone on a Siemens "Orbix" machine at Bradford Royal Infir-mary using 3M XUD film contained in a cassette fitted withT2 screens.Processing of the films was carried out using a 3M X P5()790 second processing machine. The radiographic film wasdonated by an x-ray film company and the work done out ofnormal clinical working hours. The film used for this re- .search produces considerable image detail and was thereforeideal for the purposes of this study.Several x-rays of the smaller long bones {forearm andfragments of other long bones) were produced on a "Fax-itron" machine, a portable industrial unit within the Archae-ological Sciences Department at the University of Bradford. Zafireb Paleopathnhfiy Symp 1988 Figure 7. Distal shaft of tibia of a Roman individual fromBaldock, Hertfordshire (4th century a.d.): an apparentlyoblique fracture (left) is, in fact, shown to be spiral in x-ray(right). Industrex C film and manual processing made this systemunsuitable for the research in terms of time and machinecapacity for larger long bones.The skull fractures were not x-rayed as it was consideredthat little further information could be gained by observing afilm of the injury. X-RAY ANALYSIS Each radiograph was assessed and recorded on a standardrecord sheet designed after considerable consultation of cur- rent radiographic analytical literature, especially Rogers ( 1982). Features specific to the x-ray film were recorded andincluded the following: TYPE oi- ERACTURE. The type of fracture was not alwaysclear from macroscopic observation, so an x-ray was the onlysure way to distinguish the type of break and potential causa-tion (Figure 7). 236 ? Charlotte Roberts Figure 8. Illustration of the method of measuring angulardeformity in a healed, fractured radius from a Medieval indi- vidual. Figure 9. Measurement of degree of apposition of fracturedfragments. A healed, fractured tibia in an individual from aRoman cemetery in Winchester, Hampshire. FRACTURE LINE. The presence of a fracture line on the x-raygave an indication of the stage of healing which the fracture,in relative terms, had reached. Early stages of healing willshow a clear fracture line while a long-standing fracturewould display a partially or fully obliterated line. CALLUS. The development of callus or immature bone ini-tially around the fracture site is evident, in the early stages ofhealing, on the x-ray as an area of bone with a "fluffy" outlinewith flecks of radio-dense material in it. This is evident with-in the first few weeks following the injury. As the callusbecomes older and more mature, it becomes more uniformlyradio-dense and opaque than the rest of the bone on the x-ray.As the fracture ages and the callus is calcified (from calcium salts from the bloodstream), the callus approaches the densityof normal bone. The fracture line becomes obliterated andthe trabecular pattern across the line is restored. A large amount of callus can indicate many things, butparticularly the absence of inadequate immobilization afterthe fracture allowing the fragments to move and precipitatenew bone formation.The rate of healing of a fracture is dependent on manyfactors, some of which have already been mentioned. Theanatomical part of the body affected and the age of the indi-vidual are perhaps two of the most obvious. In most cases offracture, however, the better the fracture has been treated theless the body has to work to repair and remodel the fractured area. DISPLACEMENT. Linear displacement of the fracture frag-ments was recorded by measuring the angle of displacementwith a ruler and protractor on the x-ray film (Figure 8).Attempting to measure this feature on the bone itself leads to errors. Rotational displacement of a fracture could only be Zagreb Paleopathology Symp I9H8 Trauma and treatment in the British Isles in the Historic Period ? 237 Figure \0(left). Measurement ofamount of overlap of fracturefragments in a fibula fracture ofa Medieval individual from Bil-lingsgate cemetery, London. Figure 1 1 (right). Soil in themedullary cavity of a fibulaobscuring a fracture in proximal shaft. measured roughly. The relationship of the ends of the fracturefragments to each other was also recorded (Figure 9). Muscu-lar contraction at the time of injury can make reduction offractures problematical, and this would have been particular-ly so in ancient populations. OVERLAP. The amount of overlap of the fracture fragmentsand degree of apposition could also be measured on the x-rayby direct measurement (Figured). Overlap of fragments maymean (for example in a tibial fracture) a shortened leg for theindividual and difficulties with mobility. One-third to one-half apposition of the broken fragments in a fracture is be-lieved to give a good functional result in modem populations(Figure 10). X-RAY analysis: PROBLEMS Several problems were inherent in examining x-ray films,mostly generated by the fact that archeological populationshave been buried in the ground, unlike their modem counter-parts. Soil in the medullary cavity of long bones made detec-tion of the original fracture line ditTicult (Figure 1 1) eventhough, macroscopically, there was evidence of a fracture. A Zagreb Paleopathology Symp. 1988 fracture could also be misdiagnosed by the appearance ofvascular channels in the bone shaft. Fractures of very longstanding were often so well healed that the original type offracture was not identified.On the x-ray in the callus there were often flecks of radio-dense soil particles mimicking calcified healed areas to theuntrained eye. Alternatively, radiolucent areas around thefracture site could be mistaken for infective lesions, butthe main difficulty was to determine whether the radiolucentarea was ante or post mortem.Pathological fractures were often difficult to identify, es-pecially in the case of osteoporosis underlying the fracture.Osteoporosis is a very common condition today, especially inolder women where the quality of the bone remains constantbut the quantity decreases. This is particularly seen in ribs,vertebrae and the pelvis. The osteoblast and osteoclast bal-ance is lost and the bone is liable to break under minimalforce. However, diagenetic factors working on skeletons inthe ground in cemetery sites may make the bone appear to beosteoporotic. The main problems are whether the individualhad osteoporosis before the fracture, after the fracture, orwhether it developed because of bed rest (disuse osteo-porosis) or as a postdepositional syndrome. 238 ? Charlotte Roberts The final problem with x-ray analysis is the age of thefracture. The complete healing process, in normal circums-tances, takes about one year; after that time there is littlechange histologically or radiographically in the fracture ap-pearance. It is, therefore, difficult to ascertain at what age thefracture occurred in the individual unless the incident oc-curred just prior to death. At present, in paleopathology, agesof individuals with fractures are meaningless in terms of thetiming of the fracture.We hope that work to be undertaken in the near future willgive more accurate indicators of the age of fractures in an- cient populations. Modem, documented, clinical x-raysfrom the Institute of Orthopaedics in London will be studied.The x-rays will be comparable in terms of the followingfeatures: nonoperatively treated fractures, i.e., those treatedwith basic reduction and splinting; simple, not compound,fractures; all adult individuals; fractures resulting from acci-dents not related to modem technology.These x-rays will be compared with the archeologicalfilms, and clinical records will be consulted to ascertain theage of the fracture. The same recording fomi will be used torecord the modem x-rays. The availability of clinical recordsnow provides an additional potential to assess the causes ofparticular fractures in the ancient data, to know exactly howthe fractures were treated and whether infection was present,and to observe the fracture on x-ray pre-, during and post-treatment. Modem clinical x-rays give an added time dimen- sion.Summary discussion and concluding remarks This paper has outlined the author's methodological ap-proach to trauma and treatment in the British Historic Period. It is fortunate for paleopathology that there has recently beena strong move toward this type of multidisciplinary approachin the interpretation of archeological sites.Skeletal remains from cemeteries do not represent individ-uals who lived cocooned in isolation from their environment.These people were constantly interacting with their environ-ment. As Calvin Wells said in 1964 (17):The pattern of disease or injury that affects any group ofpeople is never a matter of chance. It is invariably the ex-pression of stresses and strains to which they are exposed, aresponse to everything in their environment and behavior. It reflects their genetic inheritance (which is their internal en-vironment) the climate in which they lived, the soil thatgave them sustenance and the animals or plants that sharedtheir homelands. It is intlucnccd by their daily occupations,their habits of diet, their choice of dwelling and clothes,their social structure, even their folklore and mythology.The.se words hold true over 20 years later. Archeologicaldata, in whatever form, is fragmentary and reflects a sampleof the original deposit. The nature of this deposit and its later interpretation, whether of human skeletal remains or pottery,is influenced first by the individuals who ensured its burial orcreated an environment in which it was discarded, second byburial conditions in the ground, third by the people whoexcavated and processed the material, and last by the personwho examined the remains. The complete picture of particu-lar aspects of societies in the past is gradually lost through allthese processes. As time proceeds from true life to a distantpast, interpretation becomes more difficult, especially whenonly one type of evidence is being assessed. All types ofarcheological data are fragmentary but the maximum amountof information must be generated. Perhaps this is why re-searchers in human skeletal remains are beginning to realizethe vast potential of using other sets of data to help theminterpret data generated from human skeletal remains. Thisapproach, however, is still in its infancy.There will always be a special place in the literature forunusual and isolated pathological conditions, but in the fu-ture there will be an increasing demand for more wider rang-ing analyses of human skeletal data. It will no longer bedeemed acceptable to consider skeletons as a single entity,unresponsive to their surroundings. The use of modem clini- cal data in paleopathology will further help to broaden ourhorizons and help interpretation go further than mere diag-noses of cases. More epidemiological considerations in thefuture will enable paleopathologists to look upon their datamore critically. There is much to be learned by all partieswhether they be clinicians, paleopathologists, art historians,or ethnographers. There is also a move toward multi-disciplinary conferences (e.g., Dieppe and Rogers 1986)where exchange of ideas is encouraged.In this particular type of study it has already been notedthat the use of multiple sets of evidence creates problemswhich can, with care, be solved. Reliance on individuals whoare experts in their own fields to produce data relevant to thequestions being posed is essential. However, these data canthen be assessed by the paleopathologist and considered rele-vant or rejected. The limitations of each type of evidencebeing used have already been outlined and due consideration will be taken of these limitations in the final interpretation.The end results of this study will be (1) to assess thehealing of each fracture observed, taking into consideration all the factors relevant to healing, and extensively consultingmodem clinical data and x-rays; and (2) to consider the evi-dence for diagnosis and treatment in all periods examined,including all subject areas already mentioned relevant to di-agnosis and treatment, and to work the two sets of datatogether to interpret how well fractures in the British HistoricPeriod were being treated, what techniques, equipment andknowledge were available, in what kind of environments didfractures have to heal, and whether the type of diet individu- als were eating was good enough for fracture healing tooccur. Zagreb Pateopiithttloiiy Symp. I9fi!i Trauma and treatment in the British Isles in the Historic Period ? 239 There will be some areas of evidence grossly lacking andsome will be plentiful, but it is hoped that a representativepicture of past trauma and treatment will be produced in thenot too distant future. AcknowledgementsDue thanks go to Keith Manchester who made helpful com-ments throughout the paper, the many museums and arch-eologiai units who have allowed me access to human skeletal material, Tony Margel, Senior Radiographer at the BradfordRoyal Infirmary, for producing most of the x-rays (also to agenerous x-ray film company) and to Jean Brown, formerlyof the Photography Department of the University of Brad-ford, for producing the photographs and diagrams. There arealso many, many more people who have been helpfulthroughout this research and thanks will be given to them inthe final thesis. Literature cited Ackcmccht, E.H. 1982. Short History of Medicine. 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Italy.Siena, Italy: University of Siena. Summary of audience discussion: Dr. Pahl reported that hisdissections of Egyptian bodies suggested that the presence of a stickapparently splinting a fractured bone may in fact have been a splinton a long bone fractured post mortem, perhaps during the mum- mification process. He bases this on the common absence of bloodor reactive bone changes as well as bandages. Conscc)ucnlly hewarned that the mere presence of a splint adjacent to a fractured longbone in an Egyptian body is not invariably evidence of antemortemtreatment efforts. The presence of bony reaction in some splintedbodies, however, makes it clear that Egyptians did indeed makesome therapeutic efforts in cases of long bone fracture. Zagreb Paleopathotogy Symp. 1988 Paleoepidemiology of trauma in a prehistoriccentral California population Robert D. Junnain 1 he challenges faced by and the personal catastrophes thatbeset prehistoric peoples sometimes fortuitously leave tracesin their skeletons. One of the better perspectives from whichto obtain data concerning particularly challenging events inthe archeological past is the analysis of traumatic lesions.Several researchers have noted previously that evidence offractures, projectile wounds, and dislocations can provideinformation concerning the incidence of accidents or inter-personal violence in prehistoric populations (Elliot-Smithand Wood-Jones 1910; Angel 1974; Edynak 1976; LovejoyandHeiple 1981).A large and very well preserved skeletal collection fromthe prehistoric central Califomian site of Ala-329 offers fur-ther illumination concerning traumatic episodes in the past.Differential diagnosis and analysis of traumatic lesions in this skeletal population provide examples of severe accidents aswell as many cases of interpersonal violence. In addition,comparison of reactive changes about the hip joint seen inthis group help further clarify the distinction between trau-matic and congenital hip dislocation. Materials and methods Ala-329 is a large shell mound site located on the easternshore of San Francisco Bay, approximately 20 miles north ofSan Jose. While now located approximately 2 '/2 miles in-land, the site probably once stood adjacent to the bay shoresurrounded by saltwater marshes. Newly determined radi-ocarbon dates chronologically place the site between at leastA.D. 500 and European contact (approx. a.D. 1700).Ala-329 is a large site with dimensions extending 133 x90 X 4 m high, and no doubt contains hundreds of burials.Excavations carried out by Stanford University and San Jo.seState University mostly during the 1960s exposed 20-25%of the mound and still removed 440 burials. The sampleavailable for analysis in this study includes the 420 grave lots(representing a minimum of 440 individuals) excavated be-tween 1959 and 1968 by San Jose State University and Stan-ford University field classes. Of these, the most relevantgroup for the present study is the 248 aged and sexed Zofireh Pateopalhnlof^y Symp. 1988 adults? 138 males and 1 10 females. Overall, the conditionof the burials is good to excellent and. as such, this collection represents one of the larger and better preserved osteologicalsamples in the western United States.Moreover, most graves were undisturbed, and careful ex-cavation retrieved many elements intact. Indeed, more thanone-third of all burials could be described as "complete"(i.e., containing most major elements intact). Soil conditions at this site, apparently physically and chemically buffered bythe large quantity of shell, afforded excellent conditions forpreservation (see Figure 1).Pathological lesions were diagnosed by gross macroscopicexamination and supported by radiographic analysis includ-ing standard x-ray as well as computed tomography (CT)scans. In most cases the diagno.ses from gross specimens andradiographs were corroborated through examination by anorthopedic surgeon. Most fractures were ascertained by thepresence of angular deformity often accompanied by short-ening of the affected element. In other cases, in the absenceof gross morphological change, a diagnosis of healed frac-ture could not be supported unequivocally. Indeed, detailedexamination of more than 100 radiographs of long bones bythe author as well as an orthopedic surgeon could not find oneadditional healed fracture. Long-standing, very well healedfractures with no deformity or shortening are thought bymany researchers to be virtually impossible to detect. Somereports (notably. Lovejoy and Heiple 198 1 ) have relied uponsubtle radiographic criteria to support diagnoses of most trau-mas. While such evidence may. in fact, be applicable to somespecific cases, the ultimate effect will be to raise the apparentfracture rate in those samples to which such criteria havebeen applied, as compared to those groups (e.g., Ala-329)where such diagnoses are not supported. Results and discussion After dental disease and degenerative involvement ( Jurmain1983), trauma is the most common type of pathological le-sion seen in this population. In many circumstances it is notpossible to differentiate trauma from degenerative joint dis-241 242 ? Robert D. Jurmain Table 1. Number of intactlong bones by side Clavicle Left 143Right 148 Radius Ulna Femur Tibia Fibula Paleoepidemiology of trauma in a prehistoric California population ? 243 Figure 2. Ununited fracture of right radius. Male, 35-50 years. !iiii|inmiii|iiiMiiM|iiir|ii The second case, also a male (35-50 years of age), dis-plays an ununited fracture of the distal right radius. Most ofthe radius is missing, but the distal piece that is present has acompletely sealed marrow cavity. In addition, another smallpiece, representing the middle third of the diaphysis, also hasa sealed marrow cavity (Figure 2). The right ulna is alsofractured at approximately the same location, but showsgood healing with a slight, angular deformity.The third case of nonunion is a probable female, aged 21-30, with an ununited fracture of the left ulna 1 1 1 mm belowthe proximal end. The marrow cavity is again sealed andthere is evidence of fibrous union with extreme hypertrophicreaction particularly in the area of attachment of the pronatorquadratus. The distal piece, however, is missing. The radiusis uninvolved.The final case of nonunion is seen in the right ulna of amale, aged at more than 40 years at death. The lesion occurs73.9 mm below the proximal end, and both ends are sealedwith fibrous union. However, the bone still appears highly reactive (vascularized), and there is secondary degenerativedisease of the wrist.As seen, all cases of nonunion are of the forearm, as isconsistently the pattern in other reports of this type of lesion.All the elements described by Stewart are also in the forearm,although he does mention cases involving the clavicle andfemoral neck. Likewise, the only involved element at Libbenis also a forearm bone (an ulna). However, it must also benoted that, as a result of poor recognition and diagnosis, thistype of lesion may be considerably underrepresented in thepaleopathological literature. Indeed, in di.scussion at thesymposium and subsequent communication, several othercases of ununited fractures were noted: four from the Win-dover site in Florida (Dickel, pers. comm.) and two ca.sesfrom archaic populations of the Great Lakes region of NorthAmerica (Pfeiffer 1985, pers. comm.).Other than the forearm, fractures in general are very rare inthis population. Only eight other definite fractures of longbones are seen (two clavicles, one humerus, and five tibias). It must be emphasized that, as noted above, even with radi-ographic analysis, diagnosis of well-healed fractures is oftenimpossible.Fracture rates are difficult to compare between popula-tions, as often the frequencies are not computed by individualelements, and even where they are, the degree of complete-ness of the sample is not taken into account. Among thebetter paleoepidemiological approaches to the study of frac-ture incidence is Lovejoy and Heiple's work with the Libben Zagreb Paleopathology Symp. I98S Figure 3. Fused right hand elements; all carpals and 2d and3d metacarpals. Female, 39-44 years. population. In order to control foreffect of preservation, onlyintact long bones were included and carefully tabulated. Asimilar methodology is used here. The overall fracture inci-dence at Libben was 72/2383 (3.0%) compared to 36/2047(1.8%), that is, only about half as high in this study. Inaddition to the clear quantitative difference in frequency, thepattern of involvement also varies dramatically. At Libben,the most frequently fractured element was the clavicle, in-volved in 15/260 cases (5.8%). At Ala-329, however, onlytwo definite clavicular fractures are found in 291 intact ele-ments (less than 1%). Certainly, in modem groups, mostclavicular fractures result from severe falls (or auto acci-dents). The frequency of bad falls at Ala-329 thus appears tohave been lower than at Libben. Indeed, Lovejoy and Heiple(1981) state that from modem U.S. data the clavicle is themost fractured long bone.A particularly dramatic case at Ala-329 that did result froma severe fall is a 39-44-year-old female who had an apparentfracture to the distal right ulna (or Allen's fracture) that alsoseverely traumatized the hand. Indeed, all the carpals plusthe 2d and 3d metacarpals are fused into a solid block (Figure3). In addition, the left arm is also broken (distal left radius), all perhaps as a result of one very serious fall.Therefore, it would seem a different fracture pattem isindicated at Ala-329 compared to that at Libben. At Ala-329,severe falls were not the single primary cause of fracture. The relative infrequency of Colles' and Allen's fractures, seen inonly II cases (5 Colics'. 6 Allen's), further suggests this.Another possible explanation for the lower frequency of frac-tures seen in the Califomian population could be demograph-ic. Lovejoy and Heiple (1981) make the explicit point thatfracture risk is directly linked to longevity. And, indeed,older individuals in both samples have more healed fractures. 244 ? Robert D. Jurmain TabLH 2. Fracture incidence by element Paleoepidemiology of trauma in a prehistoric California population ? 245 iniiiiiiiii METRIC 1 ' Figure 5. Fifth lumbar vertebra withprojectile point embedded in anteriorcentrum. Female, 19-21 years. FiGLiRE 6. CT scan of same element asFigure 5. Distance A-B (16.8mm) islength of obsidian point. superior articular facet. The remainder of the projectile pointwas also found with the burial. This individual apparentlysurvived his wound as indicated by the resorption of boneabout the embedded tip.Three other cases also involve the vertebral column, one in a probable male, 15- 17 years of age, with a small point in thedorsum of the 6th thoracic vertebra (T6) just below the lefttransverse process. No sign of healing is evident. In anothercase, a male 35-44 years of age at death, a large obsidianpoint was found in th? right centrum of Tl 2 just superior tothe rib facet; the angle of trajectory indicates the projectileentered through the front, no doubt causing massive injury.Indeed, the projectile is deeply embedded, and there is nosign of healing. Moreover, there is another projectile woundin the distal end of the left radius, also showing no sign ofhealing (and thus probably resulting from the same obviouslyfatal incident). The last case of a vertebral projectile lesion is a young male, aged 20-22 at death. The broken end of anobsidian point is lodged in the right transverse process of hissecond lumbar vertebra. Since the point is broken, the angleof trajectory is difficult to ascertain; however, it appears hewas shot from the front or to the side from the front. Addi-tionally, the angle of trajectory appears to have come frombelow, unless of course the victim was shot while on theground. There is no sign of healing about the wound.Another interesting case of a projectile wound presents asomewhat different pattern, as this individual, a probablefemale aged 17-21 , was shot from the front and fairly highup with the obsidian point partially penetrating the man-ubrium. The lesion is well bounded (i.e., healed) and thusappears at least moderately long standing. Given the rela-tively young age of this individual at death, it suggests thatquite young individuals, even females, found their way intothe firing line of projectiles. Zagreb Paleopathology Symp. 1988 246 ? Robert D. Jurmain Figure 7. Left and right innominatebones, showing hypertrophy of leftacetabulum. Female, adult. The final two cases of projectile wounds both involve theinnominate. A young adult male (18-25 years) exhibits athrough-and-through lesion of the left ilium 30 mm below theiliac crest on the ventral surface, 40 mm lateral to the sacro-iliac articulation.Evaluation of the bone immediately adjacent to the pointwas inhibited by the presence of adhesive that had previouslybeen applied to hold the point in place. Nevertheless, evi-dence of reparative processes is not evident. In fact, it wouldhave been unlikely this individual would have long survivedsuch a wound. The angle of trajectory (from the front) sug-gests the projectile penetrated the descending colon, smallintestine, and intrapelvic vessels, most probably resulting inrapid death.The last individual with clear evidence of a projectilewound is an adult of indeterminate sex?a very fragmentaryburial that was mostly cremated. Here, an obsidian projectilefragment was found in the right ilium approximately 20 mmbelow the crest and 100 mm anterolateral to the auricularfacet. The probable trajectory was anterolateral in relation tothe pelvis and may have penetrated the ascending colon caus-ing intra-abdominal infection. In any case, no evidence ofhealing is seen on gross examination, on magnification, or on x-ray.The final class of trauma of note that is diagnostic in thispopulation is dislocation. Such lesions do not usually leavetheir traces on bone frequently enough to approach themepidemiologically. Still, they are of interest, especially thedifferential diagnosis of traumatic dislocation from congeni-tal problems. In this population a good example of each isseen in the hip. The first example, a probable dislocation, isin an adult female and displays considerable remodelingabout the left acetabulum, as though the joint capsule hadbeen ruptured (Figure 7 ). The femur head is preserved as only a fragment, but still shows the typical hypertrophic appear-ance of the "mushroom-head." In addition, the lessertrochanter is remodeled, possibly indicating a pulled tendon.The second case, a female 21-30 years old, has a de-formed right acetabulum. The rim is not completely devel-oped, and there is a small nearthrosis infero laterally. The femoral head is flattened interiorly and extended dor-solaterally (fitting the nearthrosis on the innominate) (Figure8). Moreover, the entire right femur appears deformed, isnarrower (maximum diaphyseal diameter immediately be-low lesser trochanter: R = 27.5 mm, L = 33.2 mm) than theleft and is twisted approximately 90? along the entire proxi-mal two-thirds of its shaft. In all respects this appears as avery good example of a congenital malformation in both theacetabulum and femur resulting in chronic dislocation ofthe hip.A third case of hip dislocation is also of interest. In thiscase (a male more than 30 years of age) the femur head isflattened and partly mushroomed. Likewise, the acetabulumis greatly hypertrophied and expanded. While no permanentdisruption of the joint or nearthrosis is evident, a probableetiology is suggested by other bony changes. On the femur a slight myositis ossificans is seen (medially 47 mm below thelesser trochanter), suggesting a muscle injury of the superiorportion of vastus internus. In addition, the anterior, inferioriliac spine is moderately hypertrophic (suggesting a furthertraumatic injury of rectusfemoris). Thus, while this case maynot present the classic picture of a major dislocation, a severetraumatic incident followed by secondary degenerative jointdisease is suggested. Conclusions While the incidence of trauma resulting from accidents is lowin this population, the evidence of interpersonal violence isunusually common. Most healed fractures that were foundare in the forearm, and a high proportion of these may haveresulted from parrying blows. In addition, the unambiguousevidence often embedded projectiles (in nine different indi-viduals plus a probable healed wound from a projectile inanother individual) is of remarkably high incidence in thispopulation.In other North American populations a comparable, highincidence of projectile wounds has not been reported fromany single site. For example, at Libben, which includes morethan 1300 individuals, no projectile wounds were detected. Zagreb Paleopathology Symp. l9Hf< Paleoepidemiology of trauma in a prehistoric California population ? 247 Figure 8. Right femur head, deformedinferiorly and dorsolaterally. Female,21-30 years. i_A_5i Even in the Old World such high frequencies of unam-biguous projectile wounds is but rarely seen. Bennike ( 1985)in a comprehensive review of basically the entire, prehistoricDanish skeletal collection (including more than 1000 craniaas well as thousands of postcranial elements) describes fiveindividuals with six projectile wounds.Indeed, the only comparable incidence comes from otherprehistoric, central Califomian contexts. Tenney (1986) re-ports 18 projectile wounds in 13 individuals from a detailedsurvey of more than 2000 skeletons housed at Berkeley'sLowie Museum. However, even here the incidence per site isless, as the material represents skeletal samples from severallocations.Thus, the Ala-329 population holds a unique position asperhaps the single most afflicted group with this type ofdeliberately induced lesion. As noted above in Tenney 's re-view, the high frequency of such wounds in central Califor- nia, particularly among San Francisco Bay groups, is not acomplete surprise. Indeed, a case of a projectile wound in acranium was received in the 19th century by the SmithsonianInstitution from a doctor in Alameda County, the same areaas Ala-329 (Wilson 1901).The evidence, clearly, is more than suggestive. Interper-sonal violence at Ala-329 prior to European contact wasfrequent, deliberate, and often fatal. In fact, the evidencefrom osseous remains almost certainly underestimates the rate of projectile wounds (and other violence-induced trau-ma), as no doubt a high proportion of wounds affected only soft tissue (see Wilson 1901 for a discussion of projectilewounds in prehistoric and historic contexts).An interesting pattern emerges in looking at the skeletaldistribution of projectile wounds. All embedded projectilepoints but one are found low in the body in the vicinity oflower thorax and abdomen (assuming the affected radius washeld down at the side when the victim was wounded). Whilepossible, it seems unlikely that such a concentrated clusterwould have resulted by chance or even by deliberate aim at Zztgreh Paleopathology Symp- l^HH distant, moving targets. Therefore, many of the wounds atAla-329 may have occurred when victims were restrained atclose range. Indeed, some of these victims may have been "executed."Summary 1 . Healed fractures in this population are relatively rare, seenin only 36/2047 intact long bones.2. Of those elements exhibiting healed fractures, the fore-arm is most often involved (13 radial and 15 ulnar fractures).3. Of these forearm fractures, an unusually high incidence(for prehistoric samples) of ununited fractures is seen (fiveelements in four different individuals).4. Frequent interpersonal violence is suggested by many ofthese forearm ("parry") fractures and even more clearly bynine individuals who have ten embedded obsidian projectilepoints.5. Two cases of traumatically induced hip dislocations arealso found; moreover, their differential diagnosis from an-other case that was congenital in origin is made clear. Acknowledgments For their direct contribution to this research and helpful com-ments on this paper, I am greatly indebted to Lynn Kilgore,Tony Musladen, and Alan Leventhal. Encouragement andassistance with the radiography were provided by MargaretBinns, San Jose State Student Health Service. The analysis of skeletal material could not have been accomplished w ithoutthe dedication and expertise of students Loma Pierce, Rhon-da Gillett. Charlene Gross, Patricia Rafter, and SandraWeldon. Grateful appreciation also goes to Bert Gerow forgenerously allowing access to the collection and to Donald J.Ortncr for his friendship and support. Financial support wasprovided by San Jose State University, School of Social Sci-ences Research Grant. 248 ? Robert D. Jurmain Literature cited Angel, J.L. 1974. Patterns of Fracture from Neolithic to ModemTimes. Anthropologiai Koztemenyek, 18:9-18.Bennike. P. 1985. Paleopathology of Danish Skeletons.Copenhagen: Akademisk Forlag.Edynak, G.J. 1976. Life-Styles from Skeletal Material. In E. Gilesand J.S. Friedlaender, eds.. The Measures of Man, 408-432.Cambridge, Mass.: Peabody Museum Press.Elliot-Smith, G., and P. Wood-Jones. 1910. The ArchaeologicalSurvey of Nubia. Report for 1907-1908, vol. 2, Report on theHuman Remains. Cairo: National Printing Department.Jurmain, R.D. 1983. Paleopathology of a Native Califomian Skele- tal Population. American Journal of Physical Anthropology,60:211-212.Lovejoy, CO., and K.G. Heiple. 1981. The Analysis of Fracturesin Skeletal Populations with an Example from the Libben Site,Ottawa County, Ohio. American Journal of Physical Anthropol-ogy 55:529-541.Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho-logical Conditions in Human Skeletal Remains. Smithsonian Contributions to Anthropology. 28. Washington, D.C.: Smithso-nian Institution Press.Pfeiffer, S. 1985. Paleopathology of Archaic Peoples of the GreatLakes. Canadian Review of Physical Anthropology. 4: 1 -7.Stewart, T.D. 1974. Nonunion of Fractures in Antiquity, with De-scription of Five Cases from the New World Involving the Fore-arm. Bulletin of the New York Academy of Medicine. 50:875-891.Tcnney, J. A. 1986. Trauma among Early Califomian Populations.American Journal of Physical Anthropology. 69:27 1 . Wilson, T. 1901. Arrow Wounds. American Anthropologist,3:513-53 Summary of audience discussion: Causes of fracture union fail- ure include recurrent violence before completion of healing andpremature use of the arm. Even in the modern period the ulna is thebone most frequently associated with nonunion. Furthemiore, fre-quency estimates of ununited fractures may be lower than realitybecause of nonrecognition. Zagreb Paleopalholngy Symp. 1988 Tumors Tumors in antiquity in East and Middle Europe Judyta Gladykowska-Rzeczycka Research on the paleopathology of tumors is problematic.There is an initial problem in deciding which osseous altera-tions can be called tumors. For example, should we includeabnormal bone growths that are the result of trauma such asmyositis ossificans? Are bone changes provoked by softtissue tumors which press on the bone and produce someform of a depression to be considered tumors? Is a bone masscontained entirely within the bone a tumor? The second prob-lem is classifying neoplasms as benign or malignant. Someinitially benign tumors may become malignant. As in otherareas of paleopathology, tumor nomenclature is a problem inour investigation. An additional factor is that the ancient skeletal material is often in a poor state of preservation.Osteolytic tumors destroy either the affected part or thewhole bone but evidence of this may be eliminated by post-mortem diagenesis. Similarly, proliferative tumors, such asosteosarcoma, are difficult to evaluate because the originalmargins of these tumors may have been eradicated eitherduring interment or later during excavation. Diagnosis ofeven well-preserved cases can be uncertain because bonechanges caused by different tumors are very similar, such asthe destructive lesions of multiple myeloma and those ofmetastatic carcinoma of the breast.Certain modem, precise instrumental methods, includinghistology and microradiology as well as scanning and trans-mission electron microscopy, permit recognition of condi-tions not diagnosable previously. However, all laboratoriesdo not yet possess such equipment so that this type of analysismay not be available in the study of many paleopathologicalspecimens. Papers dealing with tumors are principally de- scriptive and have a casuistic focus. As a result we haveinformation about many individual cases but we lack statisti- cal data. It is true that all our descriptions and statistical data will never be satisfactory, but, if well done, they can. at least,make the picture of the history of diseases more realistic. Ifwe wish to get such a picture the basic data, in every case wedescribe, must be more detailed. The basic data include num-ber of all excavated skeletons, state of their preservation,number of all pathological cases, and the sex, age. and archc-ological provenience of each case. This summary review of archeological evidence for tu-mors in Middle and Hast Europe is limited by the fact that thebasic information mentioned above is not always available.On the basis of literature at my disposal 1 will try to presentthe "state of tumors" in ancient peoples on the Baltic Coast,Czechoslovakia, ancient Russia, and Poland. Ancient Baltics The main source of information about diseases of the ancientBaltics is the book written by Derums (1970). He presentstumors from the Mesolithic. Neolithic, Bronze, and Middleages (8000 B.C. to 18th century a.d.). About 35 cases ofexostoses were observed in 505 skeletons dating from theMesolithic to the ninth century a.d., but Derums suggeststhat these are posttraumatic exostoses (p.58). Osteomas were visible in skeletons dated from the fifth to the ninth centuryA.D., but Derums described only one case?on both clavi-cles of an adult male from Kriksztonic cemetery (6th- 1 2thcentury a.d.). This exhibit is in the Museum of History andEthnography in Vilnius. Lithuania. Two more cases wereobserved among 710 skeletons dated to the 16th- 17th cen-tury A.D. One of them (No. 450) comes from Lejasviteni. inwhich the osteoma is located on the humerus. The secondcase is on the ulna. Both cases are currently in the Museum ofHistory of Medicine in Riga. Latvia. There are also two casesof osteochondroma (exostosis solitaria). One of them is onthe right tibia of a young male ( 15th- 16th century a.d.); thesecond is not described. The author noted that metastases andother malignant tumors were not observed. CzechoslovakiaMuch information about tumors comes from Czechoslovakia(Table 1 ). The skeletons examined come from 27 cemeteriesdating mainly from the Middle Ages (18 cemeteries), withtwo from the Period of Wandering Nations, one fromHallstatt (early Iron Age), one dated to the Eneolithic(Chalcolithic), and five from the Bronze Age. Table I also Zagreb Pateopalholof^y Symp. 1988 251 252 Table 1. Reports of neoplasms from Czechoslovakia Tumors in antiquity in East and Middle Europe ? 253 Table 2. Tumors from ancient Russian skeletons Tumor 254 00< T3D Oa.Bo oB3 Co ^ Co (J^ N X 41V OO si X 01to a c 2 K V cJ? c 6 X u e -o c^- c- S I c^- ^ I I Uu IO fn>0 ?' (N "^ oo r-w^ ? (N I -^ so I I n-j ( I < I < I 1 I I I I I I I I I I I I I I I I I I I I r I IE I I I ^ E ? E E g < 2 I ^ C- 2 ^ I c^- I? so r-o ^. ^-^ CnJoo o JO r4 (N I I rs I ?. c" ^ vo I ? I I I u. S O E 3 r- o E so00fM E ? <3 - i-?- a> c.- > (_ o _ X2 ? ?^ , OnNO NONO Country. Mexico City: Instituto Nacional de la Nulricion.Cohen. J. 1974. Population Difl'crenccs in Dental MorphologyViewed in Terms of High and Low Heritability. American Jour-nal of Physical Anthropology. 41:473.Cohen. M.N.. and G.J. Armelagos. eds. 1984. Paleopathology atthe Origins of Agriculture. New York: Academic Press.Cook, DC. and J.E. Buikstra. 1979. Health and Differential Sur- vival in Prehistoric Populations: Prenatal Dental Defects. Ameri-can Journal of Physical Anthropology. 5 1 :649-664.Cutress. T.W.. and G.W. Suckling. 1982. The Assessment of Non-Carious Defects of Enamel. International Dental Journal. 32:117-122.Federation Dentaire Internationale (FDI). 1982. An Epidemiologi- cal Index of Developmental Defects of Dental Enamel (DDEIndex). International Dental Journal. 32:159-167.Goodman. AH., and G.J. Armelagos. 1988. Childhood Stress andDecreased Longevity in a Prehistoric Population. American An-thropologist (in press).Goodman, A.H.. G.J. Armelagos, and J.C. Rose. 1980. EnamelHyptiplasias as Indicators of Stress in Three Prehistoric Popula-tions from Illinois. Human Biology. 52:515-528.1984. The Chronological Distribution of Enamel Hypo-plasias from Prehistoric Dickson Mounds Populations. AmericanJournal of Physical Anthropology. 65:259-266.Goodman. AH.. J. Lallo. G.J. Armelagos. and J.C. Rose. 1984.Health Changes at Dickson Mounds. Illinois (A.D. 950-1300).In M.N. Cohen and G.J. Armelagos, eds. , Paleopathology at theOrigins of Agriculture. 271-305. New York: Academic Press.Goodman. AH., D.L. Martin. G.J. Armelagos. and G. Clark.1984. Indications of Stress from Bone and Teeth. In M.N. Cohenand G.J. Armelagos, eds. , Paleopathology at the Origins ofAgri-culture, 13-44. New York: Academic Press.Goodman. A.H.. N.A. Rothschild, and G.J. Armelagos. 1983.Social Status and Health in Three Prehistoric Populations fromDickson Mounds. Illinois. American Journal of Physical An-thropology, 60:199.Hamill, P.U., T.A. Drizd, C.L. Johnson, R.B. Reed, and A.F.Roche. 1977. NCHS Growth Curves for Children. Birth- 18Years, United States. Vital ami Health .Statistics, series 2, no.165. Department of Health, Education, and Welfare PublicationPhs 78-1650.Ham. A. 1978. Misslssipplan Settlement Patterns in the CentralIllinois River Valley. In B. Smith, ed.. Mississippian SettlementPatterns. 233-268. Academic Press: New York.1980. The Prehistory of Dickson Mounds: The DicksonExcavation. Illinois State Mu.seum Report. 36. Springfield.Jelliffe, D.B., and E.F.P. Jelliffe. 1971. Linear Enamel Hypoplasia of Deciduous Incisor Teeth of Malnourished Children. AmericanJournal of Clinical Nutrition. 24:893.Jontell. M.. and A. Linde. 1986. Nutritional Aspects of ToothFormation. World Review of Nutrition and Dietetics. 48:114-136.Kreshover. S. I960. Metabolic Disturbances in Tooth Hirmation.Annals of the New York Academy of Science. 85: 161- 167.Lallo, J., G.J. Armelagos, and R.P. Mensforth. 1977. The Role ofDiet, Disease and Physiology in the Origin of Porotic Hyper- ostosis. Human Biology. 49:471-483.Lallo, J., G.J. Armelagos, and J.C. Rose. 1978. Paleopathology ofInfectious Disease in the Dickson Mounds Population. MedicalCollege of Virginia Quarterly. 14:12-23.Massler, M., I. Schour, and B. Samat. 1941. Developmental Pat-tern of the Child as Reflected in the Calcification Pattern of theTeeth. American Journal of Diseases of Childhood. 62:33-67.Miler, Ivo. 1982. Nutrition in Early Life and the Development ofResistance and Immunity. Bihitheca Nutritio etDieta. 3 1 :55-60.Moore, J., A.C. Swedlund, and G.J. Armelagos. 1975. The Useof Life Tables in Paleodemography. American Antiquity Memoir.30:57-70.Nie. N.H.. C.H. Hull. J.G. Jenkins. K. Steinbrenner. and D.H.Bent. 1975. SPSS Statistical Packagefor the Social Sciences. 2d edition. New York: McGraw Hill.Ortner. D.J. 1979. Disease and Mortality in the Early Bronze AgePeople of Bab edh-Dhra. Jordan. American Journal of PhysicalAnthropology 51:589-598.Pindborg. J.J. 1982. Aetiology of Developmental Enamel DefectsNot Related to Fluorosis. International Dental Journal, 32:123-134.Rose, J.C, G.J. Armelagos, and J. Lallo. 1978. Histological En-amel Indicators of Childhood Stress in Prehistoric Skeletal Sam-ples. American Journal ofPhysical Anthropology. 49:51 1-516.Rothschild. N.A. 1979. Mortuary Behavior and Social Organiza-tion at Indian Knoll and Dickson Mounds. American Antiquity,44:658-675.Samat, B.G., and I. Schour. 1941. Enamel Hypoplasias (ChronicEnamel Aplasia) in Relationship to Systemic Diseases: AChronological. Morphological and Etiological Classification.Journal of the American Dental Association. 28:1989-2000.Selye, H. 1973. The Evolution of the Stress Concept. AmericanScientist, 61:692-699.Swardstedt. T. 1966. Odontological Aspects ofa Medieval Popula-tion from the Province of JamtlandlMid-Sweden. Stockholm:Tiden Bamangen A.B.Sweeney. E.A.. J. A. Saffir, and R. de Leon. 1971. Linear EnamelHypoplasias of Deciduous Incisor Teeth in MalnourishedChildren. American Journal of Clinical Nutrition. 24:29-31.Thomas, R.B., B. Wintcrhaldcr. and S.D. McRae. 1979. An An-thropological Approach to Human Ecology and Adaptive Dy-namics. Yearbook of Physical Anthropology. 22:1-46.White, T. 1978. Early Hominid Enamel Hypoplasia. AmericanJournal of Physical Anthropology. 49:79-83.Summary of audiencil discussion: Dental hypoplasia appears to refiect an acute episode of ill health occurring in the presence of andsuperimposed upon a chronic one. Zagreb Palcnpaihotofiy Symp. 1988 Miscellaneous Conditions Secondary hyperparathyroidismin an Andean mummy James Blackman, Marvin J. Allison, Arthur C. Aufderheide, Norman Oldroyd,and R. Ted Steinbock While the idiopathic type of bladder stone seems to havebeen more common in antiquity (Streitz et al. 1981), renal urolithiasis has become more frequent with the industrialrevolution in western populations. The metabolic phenome-na which led to bilateral, diffuse nephrocalcinosis and renalcalculus formation in an adolescent male a millennium ago are presented together with the associated differential diag- nosis. Materials and methods The spontaneously mummified body was excavated from aburial site near the mouth of the Azapa Valley at Arica innorthern Chile. Associated burial goods identified it as amember of the Cabuza culture population (a.d. 350-1000).A total autopsy was carried out at the University of Tarapaca(Arica, Chile) with final removal of all soft tissue and paleo-pathological examination of the skeletal tissues. Followinggross examination ail identified soft tissue organs weresampled for histologic and physicochemical studies.Flat plate bone x-rays were prepared of the skull, man-dible, femurs, tibias, humeri, forearms, feet and hands, aswell as soft tissue films of both kidneys.Tissues for histologic studies were rehydrated and fixed in4% formalin and in Ruffer's .solution, after which they wereprocessed in the same manner as routine surgical tissues,dehydrated with organic solvents (alcohols, benzene, xylol),embedded in paraffin and sectioned at four microns thick- ness. Routine stains included hematoxylin and eosin,Movat's pcntachrome and Gomori "s silver stain for reticulum(Zimmerman 1976:59-61).Immunocytochemical studies for thyroid and parathyroidantigens were performed on deparaffinizcd histologic sec-tions using peroxidase-antiperoxidasc methods. Thyroid andparathyroid antibodies and other reagents were supplied byBiogenex Laboratories, Dublin, California. Positive controlsconsisted of thyroid and parathyroid tissues from recent hos-pital autopsies. Zagreb Paleopathology Symp. 1988 Oxalate crystal identification studies were carried out ondeparaffinized tissue sections as described by Johnson andPani (1962).Renal stone analysis was performed by Norman Oldroyd at the Louis C. Herring Laboratory in Orlando, Florida.Methods included infrared spectro.scopy, x-ray ditTraction,and crystallographic studies.Polarizing quality of tissue crystals was evaluated by ex-amination of histologic sections with light microscopy usingpolarizing filters.Hydrated, small (one-half millimeter) fragments of tissuefrom the neck masses were studied by transmission electronmicroscopy after glutaraldehyde fixation on a Phillips 201transmission electron microscope (TEM). Both gross tissuefragments and unstained histologic sections of the neckmasses and kidneys were examined in an Amray 1000 scan-ning electron microscope (SEM) equipped with an electronprobe for element identification by energy dispersion x-rayanalysis (EDXA). Results GROSS SOFT TISSUE FINDINGSA large perforation of anthropogenic origin was found ineach ear lobe. In the Cabuza culture this signals an elite socialstatus (shaman?). Except for the spleen, the major organsnormally present in the thoracic and peritoneal cavities wereeasily recognized and in their normal positions. Pathologicalfindings included a left lung dried in an expanded condition,held in position by adhesions between the visceral and parie- tal pleural surfaces over all aspects of both lobes. The rightlung was thin (2-3 mm) and collapsed, conforming to thecurvature of the posteromedial chest wall interior, an appear-ance common for a normal lung in spontaneously mum-mified bodies. The heart was of normal size, but much of the visceral pericardial surface was covered with a thin ( 1 mm),cream-colored layer of material which could not easily be291 292 ? J. Blackman, M.J. Allison, A.C. Aufderheide, N. Oldroyd, and R.T. Steinbock Figure 1 . Heart demonstrating fibrinous exudateon pericardial surface. Figure 3. Right kidney demonstrating moderate atrophy with granularsurface, hydroureter and adjacent calculus removed from calyx in lowerpole. nil lllkilll|lli^llli|)ll^ilil|iiiMETRIC -Ori'yjj/y-.-vy- , '' Figure 2. Section through the trachea just below the larynxdemonstrates bilateral dark-brown masses juxtaposed to thetrachea. separated from the myocardium (Figure 1 ). At the level of theinferior portion of the larynx bilateral, dark brown masses,roughly spherical and measuring 1.5 cm in diameter, werejuxtaposed to the trachea (Figure 2). Long bones appearedlighter than usual and a cross-section of the femur revealed a thin cortex. The right kidney measured 7 x 4 x 2 cm and theleft appeared to be about two-thirds as large. The pelves andcalyces on each side were well defined and each contained atleast five easily recognized calyces. Two gray calculi, mea-suring 2.5 mm and 6 mm, were found in the right kidney, onein an upper pole (Figure 3) calyx and another in that of thelower pole. Both ureters were moderately dilated to abouttwo or three times their normal diameter from the renal pelvisto the urinary bladder on each side (Figure 4). No abnor-malities of the bladder and its trigone area were evident,although the brittle, dehydrated state of the tissues made itimpossible to evaluate patency of the ureterovesical junc-tions. Gross autopsy diagnoses included bilateral hydroure-ter, right renal calculi, left renal atrophy, pericardial exudate,bilateral neck masses of undetermined nature, and mild, dif-fuse osteoporosis. MICROSCOPIC STUDIES kidneys: The tubular structure of renal cortex was cleaHyevident in both kidneys, although the architecture of the leftkidney was much more extensively destroyed than that of the right. Glomeruli were difficult to find. Irregular masses of calcified tissue were scattered through the parenchyma, thesmaller ones revealing residual traces of arterial wall or corti- cal tubules as their locale of origin. Sheaf-shaped clusters ofneedlelike crystals were scattered through the parenchyma,some within tubule lumens and others superimposed on the calcified masses. Zafireb Paleopathology Symp. 1988 Secondary hyperparathyroidism in an Andean mummy ? 293 Figure 4. Right kidney demonstrat-ing moderate atrophy and moderatehydroureter. Figure 5. X-ray of right icidney de-monstrating diffuse nephrocalci-nosis in the form of multiple small(1 mm) radiodensities scatteredthrough the parenchyma and a calcu-lus in the lower pole. LUNGS: Mild fibrosis was present, but no bacteria or patho-genic fungi were seen. heart: The light-colored material on the pericardial surfacewas amorphous, consistent with fibrin. No bacilli were dem-onstrated. neck: Although no epithelium survived, both reticulum andconventional stains identify a well-defined glandular patternwith amorphous material occupying the centers of theglandlike structures. X-RAYS kidneys: Many small (1-3 mm), irregular opacities werescattered through both kidneys, more densely in the left one.Films exf)osed after removal of the larger calculus revealedthe smaller one still impacted in the lower pole (Figure 5). Zagreb Paleopathology Symp. 1988 bones: Mild, diffuse osteoporosis was evident but no sub-periosteal erosion or cortical tunneling changes could beidentified, and the lamina dura surrounding the teeth wasintact. No cystic changes were apparent. SPECIAL STUDIES kidneys: Only a few of the crystals became refractile whenviewed under polarized light. Electron microprobe FDXAdemonstrated high levels of phosphorus and potassium inmost, calcium in a few, and small amounts of magnesium inmany. Occasionally small amounts of iron, sodium, sulfurand chlorine were present. The larger, calcified masses con-tained much phosphorus, potassium, and lesser amounts ofcalcium. Sections treated as outlined by Johnson and Pani(1962) revealed the reactions expected with calcium oxalatecrystals except that most did not stain with alizarin red S.Constituent compounds composing the larger calculus are: 294 -J. Blackman. M.J. Allison, A.C. Aufderheide, N. Oldroyd, and R.T. Steinbock Table 1. Possible causes and characteristics of bilateral nephrocalcinosis, renal lithiasis and renal failure Secondary hyperparathyroidism in an Andean mummy ? 295 many extrarenal tissues are expected but were absent in oursubject. Oxalosis appears to be a most improbable explana-tion for our findings.Idiopathic h ypercalciuria must be considered a seriouspossibility. In this hereditary condition a poorly defined met-abolic aberration causes increased urinary excretion ofcalcium which may precipitate as calcium oxalate or phos-phate. It most frequently affects adults in the fourth and fifthdecades, but has been reported in children (Potts 1983: 1929-1943). Nephrocalcinosis may also occur.Renai. tubular acidosis is an inherited defect in whichthe distal renal tubule is unable to maintain normal pH controlresulting in excretion of an excessively basic urine causingdiffuse precipitation of calcium phosphate (nephrocalcino- sis). The disease, however, is rare, usually requires a muchlonger time to destroy the kidneys, and produces discrete calculi (of predominantly calcium phosphate structure) onlyin older patients. This, too, would seem an unlikely solution toour diagnostic problem.Primary hyperparathyroidism is an obvious considera-tion. In this rather common condition? 1:1000?neoplasiacauses excessive production of parathyroid hormone. Theneoplastic lesion is usually a benign adenoma, rarely a car-cinoma, of one or more parathyroid glands, or sometimesprimary hyperplasia of all four glands. One of this hormone'sprincipal effects is bone decalcification. Unregulated hor-mone production by the tumor Hoods the kidney withcalcium to be excreted which often then precipitates ascalcium phosphate. It may do so in the form of diffusenephrocalcinosis or as discrete macrocalculi (but usually notboth in the same individual). The hormone's effect on thebones, some forms of which are more or less unique, may bedetected radiologically. These include subperiosteal resorp-tion (especially evident in phalanges), erosion of the laminadura adjacent to the teeth, and cystic-appearing lesions inlong bones rellecting the presence of osteoclastic "tumors."However, these are often most obvious in rather late or ad-vanced conditions and simple osteoporosis may be the onlyidentifiable radiological abnormality in many. Most clinicaldiagnoses ai^e made on individuals in the third to sixth de-cades. In our subject calcium phosphate is neither the princi-pal nor the central component of the renal calculi. He isyounger than most persons with this diagnosis and has noneof the radiological stigmata of primary hyperparathyroidismexcept the relatively nonspecific presence of diffuse os-teopenia.There is, however, another form of hyperparathyroid-ism?that secondary to hypocalcemia. The mostcommon condition producing a low blood calcium level ischronic renal failure. In this state, the failing kidney's in-ability to excrete phosphates results in a relentless rise inblood phosphorus content and, because of calcium's recipro-cal relationship to phosphorus, the blood calcium drops tosubnormal levels. Hypocalcemia thus provides a perpetual,pathophysiological stimulus to parathyroid hormone produc-/Uinrch Paleopathology Symp I9SS tion. The consequent release of calcium by parathyroid hor-mone from the skeleton raises and may even restore the nor-mal blood calcium level. The tissue concentrations ofcalcium and phosphorus frequently are then in a supersatura-tion range and soft tissue precipitates of calcium phosphateoccur. The kidney itself is particularly vulnerable to such anevent (diffuse nephrocalcinosis), but commonly it also oc-curs in other soft tissues. While such minute calcificationsare distributed diffusely through both kidneys, the conditionitself does not normally generate urinary calculi; any suchrenoliths are usually the product of the original renal diseasewhich destroyed the kidneys. In children the chronic, de-structive, primary renal condition leading to secondary hy-perparathyroidism is by far most commonly chronic pyelone-phritis (Kissane and Smith 1969:755).Other conditions causing nephrocalcinosis seem most im-probable. The hypercalcemia of sarcoidosis is almost invar-iably accompanied by infiltrations in other organs, absent inour subject (Longcope and Freiman 1952). Renal corticalnecrosis spares the medulla, which was also destroyed in thismummy's kidneys. Medullary sponge kidney spares the cor-tex, again not consistent with the total kidney destructionpresent in the Cabuza's kidneys (Heptinstall 1983). Hisbones also revealed no discrete osteolytic lesions (car-cinoma; blood dyscrasias). Milk alkali syndrome is causedby excessive alkali ingestion for peptic ulcer disease: it mayproduce mild renal insufficiency. As a presumed shaman(large ear lobe perforations) he undoubtedly indulged in ritu- al practice of coca leaf chewing accompanied with alkali toenhance the leaf's alkaloid extraction, but it is not probablethis would have involved sufficient alkali ingestion to dupli-cate the effect of the milk alkali syndrome. There is no reasonto suspect hypervitaminosis D.The composition of this mummy's renal calculus is ofspecial interest. While calcium oxalate is certainly the domi-nant crystal present (nearly 30% of the stone's weight), sig- nificant amounts of struvite and carbonate apatite (each 1 0%)are also noted and seem to be distributed diffusely throughthe calculus. In addition it is important to emphasize that halfof the calculus was composed of blood, proteins, andcalcified tissue. More so than in purely metabolic conditions,this calculus appears to have been initiated by precipitation ofrenal salts within necrotic, hemorrhagic tissue debris (a "ma-trix" stone). It appears to us that, while several of the discussed condi-tions are possible, the nature of the calculus together with thepattern of renal destruction in this age group imply that theinitiating event was a probably primary, bilateral renal dis-ease with calculus formation resulting from local tissue ne- crosis. Gradual onset of progressive renal failure produced auremic state causing fibrinous pericarditis as well as second-ary hyperparathyroidism. The latter complication is then re-sponsible for the observed diffuse, bilateral nephrocalcinosis via the mechanism outlined above, as well as for the diffuseosteoporosis. 296 ? J. Blackman, M.J. Allison, A.C. Aufderheide, N. Oldroyd, and R.T. Steinbock The nature of the postulated primary renal disease cannotbe established histologically; this only reveals diftusely de-stroyed, fibrotic and calcified parenchyma of end-stagechronic renal disease. Chronic pyelonephritis would be sus-pected on the basis of frequency, though the inflammatory cells would not be preserved in a spontaneously mummifiedbody. The noted size asymmetry is common in this condition.Glomerulonephritis does not normally produce calculi. Nocongenital renal deformities are recognizable. Furthermore,the formation of calculi in an infected kidney is a well-knownphenomenon. Somewhat disturbing is the fact that struviteaccounts for only 10% of the stone's weight, but in chronicpyelonephritis the organisms may be minimal or absent in thelate stage of the disease, and many crystals may have beenadded to the calculus during the terminal stage of secondaryhyperparathyroidism.The bilateral, moderately dilated ureters are most easilyexplained by assuming the passage of previous calculi withtransient, obstructive episodes.The nature of the bilateral neck masses could not be deter-mined beyond equivocation. While their histologic patternsuggests a glandular nature, immunologic procedures couldnot differentiate between thyroid or parathyroid tissue. Nor-mal thyroid tissue (and certainly also the small, normal para-thyroid glands) cannot usually be identified in spontaneouslymummified bodies (Gerszten et al. 1976). Even if positivelyidentified as parathyroid, their multiple, enlarged statuswould not be useful in separating primary from secondaryhyperparathyroidism since 15% of the former and 100% ofthe latter reveal enlargement of more than one gland.The mild pulmonary fibrosis is most likely secondary toinhalation of the soil dust visualized in the histologic sectionswith polarized light and identified by EDXA (El-Najjaretal.1985:274). It is conceivable, however, that the major episodeof left pneumonia (evidenced by massive left pleural adhe-sions) suffered at some previous time may have caused bac-teremia and been the source of the original pyelonephritisepisode.In summary, this 18-year-oId Cabuza male most likelysuffered renal destruction from chronic pyelonephritis withsecondary renal urolithiasis, chronic renal failure, uremic pericarditis, and secondary hyperparathyroidism leading todiffuse, bilateral nephrocalcinosis. Alternative diagnoses ap-pear to be less probable. Literature cited El-Najjar. M.. A.C. Aufderheide. and D.J. Ortner. 1985. PreservedHuman Remains from the Southern Region of the North Ameri-can Continent: Report of Autopsy Findings. Hitman Pathology,16:273-276.Gerszten, E., M.J. Allison, A. Pezzia, and D. Klurfeld. 1976.Thyroid Disease in a Peruvian Mummy. MCV Quarterly, 12:52-53.Heptinstall, R.H. 1983. Pathology of the Kidney. 1599-1634.Boston: Little. Brown and Company.Johnson, F.B.. and K. Pani. 1962. Histochemical Identification ofCalcium Oxalate. Archives of Pathology, 74:347-351.Kissane, J.M., and M.G. Smith. 1969. Pathology of Infancy andChildhood. St. Louis: C.V. Mosby.Longcope. W.T , and D.G. Freiman. 1952. A Study of Sarcoidosis.Medicine, 31:1-132.Potts, J.T., Jr. 1983. Disorders of Parathyroid Glands. In R.G.Peterson et al. , eds. . Harrison s Principles ofInternal Medicine.New York: McGraw-Hill.Streitz, J.M.. AC. Aufderheide, M. El-Najjar. and D.J. Ortner.1981. A 1 ,500- Year-Old Bladder Stone. Journal of Urology,126:452-453.Zimmerman. MR. 1976. A Paleopathologic Archeologic Inves-tigation of the Human Remains of the Dra Abu El-Naga Site,Egypt Based on an Experimental Study of Mummification.Ph.D. dis.sertation. University of Pennsylvania. Ann Arbor: Uni- versity Microfilms Intemational. Summary of audience discussion: The stone consisted of 50%organic matter whose nature is speculative, but could have been asloughed renal papilla. The absence of osteitis fibrosa cystica(parathormone-induced foci of bone lysis filled with fibrous tissue)is probably the consequence of the shorter time period available inthe secondary form of hyperparathyroidism. Morphologic evidenceof hyperparathyroidism can, however, still be recognized in ancient skeletal tissues by the "swiss cheese" pattern in trabeculae producedby the tunneling effect of parathormone-stimulated osteoblastic clusters. Zagreb Paleopathology Symp. 1988 Noma?cancer aquaticus: First indication ofthe skin involving disease in ancient Egypt? Wolfgang M. Pahl and W. Undeutsch Paleopathological publications onEgyptian mummies sporadically reportskin lesions, which are usually the re- sult of trauma and very often connectedwith skeletal damage, whereas there islittle evidence of pathological changesof the soft tissue only, especially theskin (Sandison 1967; Ruffer and Fer-guson 1911; Pahl 1986). This fact can-not be explained by a lower incidenceof such diseases in antiquity?ampleevidence as well as therapeutic adviceis provided, for example, by the Pa-pyrus Ebers, the Hippocratic Corpus,or Celsus's reports. The paucity ofcases could be due either to the poor state of tissue preservation or to the lackof special research projects in this field.In a smaller number of cases the em-balming substances applied to the bodysurface of the mummy prevent an ade-quate evaluation of the object.Presentation of the following casu-istry is justified on the grounds of the rarity of soft tissue pathology and themacroscopic uniqueness and singular-ity of such a finding in mummy remainsfrom ancient Egypt. As far as we know,no comparable case has been reportedfrom other geographical regions. Material and methods The object under investigation is thehead of a male, adult mummy about 30years of age. Provenience: LowerEgypt. Date: Late Period. It is stored inthe Egyptian mummy collection of theInstitute of Anthropology and Human Zagreb Paleopathology Symp. 1988 Genetics at the University of Tubingen, registration No. 1565.In addition to a detailed macroscopicinspection, microphotographs with dif-ferent stains were prepared from mostof the ulcerations. Radiological inves-tigations, including orthopantomogra-phy, were carried out. Description of lesions It was possible to identify a total of fiveskin defects. Based on their exterior ap-pearance it can be stated with almostcomplete certainty that at least four ofthese are of the same origin.Lesion I: Region of the jaw, approxi-mately 10 mm right lateral to the medi-an sagittal line on the level of the lowercanine. The lower lip is partly involved(Figures 1,2,7,8).Lesion II: Region of the infratem-poral facies of the right maxilla, imme-diately cranial to the 2d upper molar.Exposure of the gingiva (Figures 2,9,10).Lesion III: Left buccal region at thelevel of the lower margin of the zygo-matic bone (Figures 1 ,3, 1 1 ).Lesion IV: Region of the right innermandibular angle, near lesion II (Fig-ures 2.9.10).Lesion V: Region of the right exter- nal mandibular angle, immediately onthe frontal cord of the sternocleidomas-toid muscle (Figures 2,12).Lesions I-IV are characterized by anirregular, circular, sharply defined, al-most punched-out appearance; ulcera- tion of all soft tissue down to the bone;and almost uniform size of ca. 15 mmin diameter. Lesion I shows a steeplysloping, craterlike margin. There is noouter wall and no recognizable colorchanges or scars. Minute perforationsand tunnel formations caused by insectsare to be found in the area of lesion IIIand in other skin regions outside theface. Except for lesion III, in which twoperforations of the maxillary bone areobservable?most likely caused by anapical tooth abscess, no further osseousdestruction traceable pathologically tothe soft tissue lesions was detectedmacroscopically.Lesion V, located outside the frontaland lateral part of the face, cannot becompared either macroscopically or to-pographically with the other ulcera-tions. Rather, it is a partially smooth,oval cavity with a diameter of ca. 12mm and a depth of ca. 14 mm, with a slightly punctured surface on the bot-tom connected to the soft tissue of theneck. Discussion Taking into account the missing body ofthe mummy, which precludes a differ-entiation between local and whole bodyinvolvement of the soft tissue, diagnos-tic considerations based on the follow-ing criteria can be evaluated with alldue consideration: localization, num-ber, limitation, shape, and extension ofskin lesions I- V. They are supported byradiological and histological findings.297 298 ' Wolfgang M. Pahl and W. Undeutsch Figures 1-3. Specimen No. 1 565 (Provenience: Lower Kgypt. Date; Late Period)of the Mummy Collection of the Institute of Anthropology and Human Genetics,University of Tubingen (F.R.G.): /, anterior view showing skin ulcerations L HI;2, right lateral view with skin ulcerations I. II. IV, V; 3. left lateral view showingskin ulceration III.Figures 4-6. Radiographs of specimen No. 1565: 4. posteroanterior projection;5, right lateral projection: 6. left lateral projection. In none of these projections is itpossible to identify osseous destruction. First, a postmortem origin of the de-fects definitely can be excluded. Theradiological investigation in posteroan-terior and right and left lateral projec-tions (Figures 4-6) as well as the dentalx-ray (orthopantomography) (Figure13) reveal no signs of osteolytic, meta-static or primary destruction. Instead, apathological dental process was de-tected, which corresponds to the al-ready mentioned small perforations ofthe maxilla at exactly the same level ofsoft tissue lesion III (Figures 1 .3, 1 1 ar-rows, 1 3 arrow). Another examinationwith a stereoscopic dissection micro-scope proved that the osseous defectcorresponds to the apparent apical ab-scesses of the left upper premolars. In all probability, this has no relationshipto the cutaneous lesion HI. It can there-fore be postulated that the skin foci arelesions of the soft tissue only, which, atleast to date, have not involved thebone.Based on the above remarks, thetypes of diseases relevant for a differ-ential diagnosis of lesions I-IV wouldbe the following:tuberculosis, tropicalulcer, ecthyma, cutaneous leishmania- sis, treponematosis, noma (cancrumoris, cancer aquaticus).Because of differing characteristicsigns, the following diseases shouldnot be considered in the differentialdiagnosis: nocardiosis, actinomycosis(shape, developing stages), nontuber-culous mycobacterial ulcer (irregularlimited lesions, localization), skin tu-mors and secondary deposits of tumors(development, limitation of the foci),and lepromatous ulceration (shape, de-veloping stages, localization, bone in-volvement). TUBERCULOSIS In cases of tuberculosis, the lungs andintestines are the primary sites of infec-tion. Dermatological manifestationsare extremely rare. Differences be-tween these and ulcerations I-IV con-cern the number of defects (few intuberculosis), their shape (irregularmargins in tuberculosis), extension(mostly shallow ulcerations secondary Ziifireh Paffopatholnay Symp. 19Hfi Noma in an Egyptian mummy? ? 299 Figures 7-12. Close-up of skin ulcera-tions 1-1V in specimen No. 1565: 7,8. different views of ulceration 1: teethand part of mandibula exposed; y, softtissue ulceration II and IV; 10. ulcera-tion II after biopsy (/, periosteum.2. maxillary bone); //, ulceration IIIwith exposed maxilla; perforation dueto an apical tooth abscess on level offirst upper premolar (arrows): 12, ul-ceration V with exposed right styloidprocess on bottom of cavity farrow)(I, ascended mandibular ramus). to a papulous initial stage) and mor-phology of the lesions (Kalkoff 1981).Although there can be no doubt that theancient Egyptians were affected by atleast skeletal tuberculosis (Sandison1972; Zimmerman 1977), the skin le-sions I-IV in case 1565 were notcaused by Mycobacterium tuberculosisof human or bovine form. ECTHYMA Ecthyma simplex is a pyogenic infec-tion caused by alpha-streptococcus(Korting and Denk 1974:549-550) andfound in subtropical and tropical areas.Malnutrition and poor hygiene promoteits occurrence. After an initial pustuiantstage, deep necrotic ulcerations mayfollow. These can be of polymorphicshape; in addition to irregularly shapedcircular lesions, punched-out defectsappear. The regressive phase is charac-terized by formation of scar tissue andhyperpigmentation of the marginalzone. Neither stage is present in thecase under discussion. The mono-morphic size of the lesions I-IV and thedepth of the ulcers to the bone clearlydemonstrate the incompatibility of theselesions" appearance with ecthyma. FiGURF. 13. Dental x-ray (orthopan-tomography). Arrow indicates an os-teolytic area, corresponding to maxil-lary' tooth abscess mentioned in Figure 1 1 , being in close contact to ulceration III. Zagreb Paleopathology Symp. 1988 300 ? Wolfgang M. Pahl and W. Undeutsch TREPONEMATOSIS It seems that there are no sure indica-tions that diseases caused by Trep-onema pallidum infected the ancientEgyptian population (Sandison 1972:218). Nevertheless, some of these in-fections have to be included in the dif-ferential diagnosis because the defectsin case 1565 are similar to lesions ap-pearing in the extragenital primarymanifestation of primary lues, in sub-cutaneous syphilides of tertiary lues,and occasionally in yaws?a non-venereal type of treponematosis. How-ever, extragenital manifestations areless frequent than genital ones and usu- ally appear as a single lesion. Nor-mally, they do not reach the degree of soft tissue destruction detected in indi-vidual 1565 (Luger 1981). Similar rea-soning can be applied in regard to theadvanced stage of syphilis. Another,more important argument for not cor- relating the disease in the investigatedspecimen with venereal and non-venereal syphilis is the morphologicuniformity of lesions I-IV. Further-more, yaws is a disease of subtropicalclimates, and accordingly its occur-rence in Egypt is far less probable than,for example, the nonvenereal endemicsyphilis found today in the Nile Delta(Maleville 1976). TROPICAL ULCER Tropical ulcer is a phagedenic ulcer pri-marily found in tropical and humid cli-mates. Established lesions contain fusospirochaetal organisms, but it isunclear whether these are the primaryinfecting agents. Epidemics have beenreported from northern Africa. Follow-ing erythema a pustule develops, fol-lowed in turn by a sharply limited,circular or oval ulceration with under-mined, slightly raised margins. Laterthe margin hardens, further deepeningthe crater to the point of exposing thebone (Connor and Neaffie 1976). Mal- nutrition, inappropriate treatment, un-hygenic living conditions, and con-tamination of the ulcers are factorswhich prevent healing. Such defects arelocated primarily on the distal part ofthe leg above the malleoli (compareHaneveld 1974). The diagnostic differ-ence between tropical ulcer and lesionsI-IV consists in the former's raisedmargins, isolated lesions, and charac-teristic location on the lower ex-tremities. CUTANEOUS LEISHMANIASISAn infection of the skin by a protozoanof the genus Leishmania includes threeclinical-pathological entities. One ofthem, the tropical sore, must be in-cluded in the differential diagnosticpossibilities. It represents a single le-sion caused by Leishmania tropica.Geographical distribution: tropics andsubtropic; sporadic in the southern partof Europe. Predominantly the un-clothed regions of the body (mainlyface) are involved. The disease showscircular or oval, sharply limited, partlyraised margins, and its development be- FiGURE 14. Diflferentdegreesofnoma in clinical patients. Photos courtesy of ArmedForces Institute of Pathology, Washington, D.C. gins with a local erythema, followed bypustules and papules, and finally a shal-low ulceration (Braun-Falco et al.1984:178-181). Normally the lesionsdisappear after one year and a scar re-mains. Distinctive marks concerningthe lesions in case 1565 are the slightouter wall, the depth of the ulcerations,the absence of bone exposure and thestages of the growth process. NOMA (CANCRUM ORIS)Noma is an acute, progressive, necro-inflammatory process of unknown ori-gin. It involves the soft tissue of theface and during later stages the facialskeleton as well. Although spreadthroughout the world, noma is rare inwestern Europe and North America(Joseph and Duncan 1976). In recentyears, it has been reported in Africa andAsia. The disease corresponds to theso-called cancer aquaticus of the Mid-dle Ages and was prevalent during that era. Predisposing factors include im-mune deficiency due to malnutrition orconsumptive diseases. Bacteria iso-lated from the base of the lesions ofteninclude spirochetes, corynebacteriaand others, but it is more likely thatthese represent secondary contamina-tion. The prognosis of the disease wasfatal in the preantibiotic era and is stillsevere today (Tempest 1966:949). Themacroscopic appearance of noma cor-responds in its essential features to le-sions I-IV of subject 1565. The local-ization (facial region), number of foci(multiple lesions are reported), exten-sion (exposure of the bone), shape andsize of the ulcers are in absolute agree-ment with lesions I-IV. Differences do exist, such as those concerning the ageof the involved patients, which aremainly infants in present-day clinicalmedicine (Figure 14).In addition to the hitherto diagnosticconsiderations, lesion V (Figure 12),located in the right mandibular angleand clearly defined, should be dis-cussed. Obviously there is no mor-phological similarity between lesion Vand lesions I-IV. Nevertheless a patho- Zagreb Paleopathology Symp. 1988 Noma in an Egyptian mummy? ? 301 genie eonneetion could be postulatedfor the following reasons: ( 1 ) most ofthe lesions (I, II, IV) are located in the right part of the face; (2) lesion V islocated on the level of the middle groupof the nodi lymphatici cervicales pro-fundi which collect the lymph comingfrom the head and neck region; (3) thediscussed diseases cause a more or lesssevere reaction of the lymphatic sys-tem, that is, lymphoid hyperplasia orulcerative lymphangitis.However, investigation of the mar-gin of lesion V by means of a ster-eoscopic dissecting microscope revealsthat no inflammatory or healing processcan be detected. Furthermore, it has notbeen sufficiently proven whether thepenetrating defect on the bottom of thecavity exposing the styloid process wascaused either intra vilam or post mor-tem. We assume that lesion V corre-sponds to a calcified lymph node cavity(as it is occasionally diagnosed relativeto tuberculosis) or to a cystic benigntumor. Any connection with lesions I-IV is conceivable, but not necessary.Due to the brittle surrounding tissue,histological sections could not be pre-pared from this anatomical region.Instead of this, and with the aim of amore detailed diagnosis, biopsies of ul-cerations I, II and III were investigatedhistologically. Besides the partly pre-served epidermis, groups of cellularelements could be observed, whichconsisted of clusters of either spindle-formed, oval or circular cells (Figures15,16). Erythrocytes and most proba-bly leukocytic infiltrates were identi-fied (Figures 17.18). In Figure 15,tissue surrounds the circular cell cluster(arrows). Most likely it is a vascular wall; therefore, the formation could beinterpreted as a cross-section of blood vessels. Despite the application of di-verse staining methods such as Ziehl-Neelsen, Gram, Giemsa, PAS, haema-toxilin-eosin and Azan, it was impossi-ble to get clear indications for the in-volvement of the ulcers by microorgan-isms relating to one of the discussedpathological conditions. One of theproblems is that there is no verification Wa Figures 15-18. Microphotographs (specimen 1565) taken from histological sec-tions (ulceration III): 15, different cell types partly conglomerated into oval cell clusters, Giemsa, x68; 16, cell clusters, Giemsa, x243; 17, close-up of cells fromFigure 16, showing possible erythrocytes, Giemsa. x243; 18, close-up of cell-typesout of Figure 16, most probably showing leucocytes. Giemsa. x243.Figure 19. Nonidentified organic structure with regular internal septations, parasi-tic infection? Giemsa, x243.Figures 20,21. Oblong, bacterial (?) elements in chainlike arrangement. Giemsa,X400. of the antemortem origin of the worm-like, organic structure and bacterial (?)elements demonstrated in Figures 19-21. It is remarkable, however, thatcomparative, cutaneous examinationsof the same subject as well as our stud-ies of mummified skin preparations from other samples of the same mum-my collection did not disclose parallelfindings. Unfortunately, there are in- sufficient, satisfactory histopathologi- cal investigations of Egyptian mum-mies' soft tissues at the present time,so that an analysis of the above- Zagrrb Pateopathotogy Symp. 1988 302 ? Wolfgang M. Pahl and W. Undeutsch mentioned findings cannot offer a con-clusive, scientifically proven diag-nosis. As in so many areas of Egyptianpaleopathology, a systematic researcfiprogram is recommended fiere (see be-low). Until tfien it will be difficult torefute such claims as tho.se in Sand-ison's paper on infectious diseases inantiquity, that "macroscopic examina-tion and radiographic studies are morelikely to give useful information thanhistological preparations" (1972:222). ConclusionsCompared with the clinical possibilitiesof dermatological or internal medicineconditions, the identification of patho-logically caused soft tissue lesions inmummies represents simply a minimaldiagnostic. In addition to absent color,the typical soft tissue character of theskin is lacking and the skin itself ismore or less destroyed by postmortemdecomposition, mummification sub-stances, and often by long-term stor-age. The normal arrangement of layers,color and cell structure has often beenaltered. In a limited number of casesparasitic infection is demonstrated his-tologically. Nevertheless it remains arisky enterprise to diagnose soft tissueinvolvement resulting from any diseaseof nontraumatic and nonparasitic ori-gin.With caution, yet supported by thewell-preserved and characteristic le-sions, it was possible to arrive at a prob-able diagnosis. In the process it becameincreasingly clear that, except for oneparticular disease, the other mentionedconditions exhibit distinct differencesrelative to lesions I-IV. In light of theavailable criteria (particularly the typi-cal configuration of the ulcers, their lo-calization, and the exposure of skeletalparts) it seems highly probable that thecause of ulcerations in mummy 1565 isnoma. The fact that noma occurs moreoften in children in present-day patientsdoes not contradict the diagnosis, sinceadults are affected as well, although infewer numbers. It can be assumed thatnoma was known in the Egypt of thepharaohs when one takes the living conditions of the masses into account.Because the harvest was dependent onthe degree of Nile flooding, famineswere common and contributed to one ofthe predisposing factors of phagedeniculcer: malnutrition, poor hygienic con-ditions, and the accompanying immunedeficiency.Attempts to identify noma in writtenmedical sources from Egypt have beenundertaken by Ebbell (1939), who con-cluded that case 15 of the Edwin Smithsurgical papyrus is a description ofnoma: Ca.se 15 (6.14-17). Instructions con-cerning a perforation in his cheek: "Ifthou examinest a man having a per-foration in his cheek, shouldst thoufind there is a swelling, protrudingand black, [and] diseased tissue uponhis cheek, (conclusion in diagnosis]. "Thou shouldst say concerninghim: 'One having a perforation in hischeek. An ailment which I will treat."Thou shouldst bind it with [ymrwjand treat afterward with grease |and]honey every day until he recovers."From the viewpoint of modem clini-cal medicine, this presentation wouldseem to be too sparse to assign therespective symptoms?consisting ofonly three items: a hole in the cheek, akind of swelling, and a black color-ing?to the family of phagedenic ul-cers, much less to the disease "noma."James H. Breasted (1930), in histranslation of the Smith papyrus, statesthat case 15 describes a traumatic per-foration of the maxilla (according toBreasted, "cheek" is a designation forthe maxillary bone, zygoma, and partof the temporal bone) resulting in aninfection of the soft tissue wound in-volving swelling and blackening of theinjured region. This could possibly bediagnosed as a type of gangrenous ornecrotizing pyoderma. Due to its deter-minative, the word | ^>m J Cimrw)may denote a mineral substance whichwas part of the ancient Egyptian mate- ria medica, perhaps a disinfectant(compare Grapow 1956:129). Thus,because many pathological aspects ofcase 15 remain ambiguous, the papyrus text does not confirm Ebbell's diag-nosis sufficiently.In spite of this, it seems rather certainthat noma was well known in antiquity.In Book VI of "de medicina," A. Cor-nelius Celsus reports a disease whichPatrick regards as noma and not asstomatitis aphthosa (Patrick 1967:243): But those ulcers, which the Greek call aphthae, are by far the most dan-gerous, that is, in children, for theyoften kill them; in men and womenthere is not the same danger. Theybegin at the gums, next possess thepalate and the whole mouth, then de-scend to the uvula and fauces. Whenthese are affected, it is not easy forthe child to recover (AC. Celsus,book VI, translation according toGreive 1756). Finally, we cite an epigram of the Latinwriter Martial, describing a diseasewhich could have been noma: Canace, the daughter of Aeolis, liesburied in this tomb; little Canace,whose seventh winter was her last.Alas for the guilt and the crime of it!Thou, passer-by, who art quick weep,may lament here, not the shortness oflife, but something sadder than death,the way death came. A dreadfulcanker wasted her face and settled onher tender mouth, and consumed hervery lips before they were surren-dered to the smoky pyre. If it had tocome with so ill-timed a flight, fateshould have come by another path.But death hastened to close the chan-nel of her charming speech, lest hertongue might have power to bend thestem goddesses (Patrick 1967:243). General remarksWe would first like to state that theideas and considerations expressed hereshould not be understood as an appealfor a retum to the descriptive style ofpathology which, especially in the areaof paleopathology, has fallen into dis-credit in the last few years. The aver-sion to it may have drawn its justifica-tion from the habit, common in the area iCuf-reh /'(ilnipiilluilii);\ Svmp IV8S Noma in an Egyptian mummy? ? 303 of paleopathology, to merely describe "cases" without including any subse-quent discussion of the global featuresof a particular disease (i.e.. relating asingle case to the frequency of a partic- ular disease in a defined geographicalregion, or to pri)ject a certain diseaseagainst the background of all diseasesendemic to a certain locality). Our un-derstanding of the term "descriptive" isnot limited to "merely describing" vis-ible, exterior characteristics. In addi-tion to comprehending "visual" or "macroscopic" phenomena, scientificdescription, as the word implies, alsoencompasses the entire range of whatcan be perceived, that is, what remainshidden to the unaided eye and can onlybe "seen" with the help of analyticalmethods. The case presented here fromthe field of soft tissue pathology pro-vides an opportunity to refer to descrip-tion as the conditio sine qua non of sci- entific work and interpretation. It is offundamental importance for any indi-vidual as well as comparative study and essential for every experimental model.Contrary to the widespread misconcep-tion, however, description must be re-garded as a pars pro toto and not as anexclusive whole. To be of any scientificrelevance, it must necessarily serve adefined goal, strive for knowledge and,if it is not to become an end in itself, becomplemented by interpretation.The study presented above is by ne-cessity a descriptive one. Using variousmethodological procedures, it is a se-lective description of "externa" as well as "interna." Due to the unique charac-ter of its findings, at least for the paleo-pathology of ancient Hgypt, it con-ceivably could be concluded at thispoint and presented for subsequent dis-cussion. Above all, this means that theopportunity to compare its findingswith related anthropological cases islost and creates problems in locating relevant, diagnostic information con-cerning the alleged disease "noma" inmodem medical literature. In terms of ahistopathological account of the find-ings, there is no unanimous consensusconcerning the origin of microorga-nisms occasionally seen in the lesions. The question of whether these coloniesof microorganisms represent secondarycontamination or a primary coloniza-tion by a pathogen has yet to be an-swered satisfactorily.In our study we have attempted to gobeyond a merely descriptive methodand by the process of elimination for-mulate a differential diagnosis based onthe macroscopic appearance of the de-fects as well as additional informationobtained from x-ray procedures andconventional histology. Furthermoremedical texts from ancient Egypt relat-ing to the clinical picture of "noma"were examined in detail. This resultedin a probable diagnosis and the emer-gence of new, fundamental questions relating to the field of soft tissue pathol-ogy. For our purposes the question ofprime importance is the paradox thatmedical papyri from Egypt contain alarge volume of direct and indirect re-ports concerning skin diseases orpathological skin manifestations, butthe amount of anthropological evidenceis very scarce indeed. To state it verysimply, this means that although Egypthas provided more subjects for anthro-pological study than any other single culture, no more than a handful of der-matological clinical cases are known.What are the reasons for this pathetic situation which discourages and evenhandicaps us in formulating any con-crete statements concerning an individ- ual case other than a purely descriptiveone? Are they due to insufficienttechnical-diagnostic possibilities? Toan inadequate inspection of the subjectsunder study? To the state of preserva-tion of organs or soft tissue? Or do thewritten records constitute an inap-propriate yardstick for calculating thefrequency of diseases which may haveoccurred to a much lesser extent thanthe historical sources suggest? It is difficult to provide an explana-tion for this phenomenon. In our view,the primary reason for this is the factthat up to now qualified specialists havenot conducted selective studies on thepaleopathology of skin and soft tissue.Based on our own experiences duringarcheological excavations in Egypt the superficial examination of bodies (atleast those which are found withoutwrappings) is not sufficient in itself.One must also conduct a precise inspec-tion of darkened skin with definitequestions in mind and employ all ap-propriate instruments. At the same timethe necessary arrangements should bemade concerning the taking of samplesand their preservation until they reachthe laboratory.As another important aspect for fu-ture research in the field of soft tissuepathology (as well as in the area of os-teopathology), we would like to con-sider ways to increase the effectivenessof specimen evaluation. In the past thishas been carried out mainly by individ-uals without consulting a group of spe- cialists which should have included notonly paleopathologists, who are famil-iar with the characteristic propertiesand appearance of mummified softtissue, but also clinicians. Such a com-mittee should be made up of expertsregardless of nationality. Criteria fortheir participation in diagnostic evalua-tions should be based on proven com-petence, prior experience in investigat-ing mummified tissue, and the ability toapply methods best suited for a specificanalysis. The publication of the resultsthus represents a joint effort of all per-sons and institutions involved. Thisproposal means that scientists shouldbe willing to sacrifice their egotisticalinterests for the sake of group consulta-tion, that is, that each individual recog-nizes the limits of his or her owncapabilities when investigating a bt>dyand has the courage to delegate the cor-responding tasks and decisions to thosemore authorized, regardless of geo-graphical or political boundaries. Thisproposal requires explicit and definedgame rules which nonetheless shouldnot deviate too much from those un- written laws of fairness and considera-tion already common among scientistsin their dealings w ith one another. Yet itis also essential that the mammoth con-gresses of today be replaced by smaller,more comprehensible gatherings withthe possibility for clVcctive group workand di.scussion of current problems. It Zagreb hileopathology Symp. I9HH 304 ? Wolfgang M. Pahl and W. Undeutsch seems to us that the symposium "Hu-man Paleopathology: Current Syn-theses and Future Options'" of this con-gress has taken the first steps in thisdirection and that this represents a re-freshing contrast to similar congressesin the past.The future tasks of paleopathologyhave become too varied and compli-cated to be left to the exclusive judg-ment of individuals. They require acooperative plan which is considerablyfree of personal egos and which goesbeyond that positive development gen- erally referred to as "interdisciplinary"research. "Interdisciplinary" not onlymeans consulting a certain specialistfrom an area outside one's own. butalso calling in a specialist from one'sown field of paleopathology. It not onlymeans consulting the nearest specialistto solve a particular problem but alsoinvolves the necessary orientation to-ward the international arena, regardlessof rivalries, for the sake of meaningfulresearch. Only then will such combina-tions promise the optimal utilization offacts and methods on one hand, and thelargest possible accumulation of knowl-edge, for the question at hand as well asfor the entire field of study, on the oth- er. What is needed is more concertedaction and less insulation of interests inthe hopes of acquiring personal fame.The case we have presented repre-sents an exhaustion of all applicablemethods at our disposal. We do not feelcompletely qualified to apply immu-nological techniques such as those usedsuccessfully by Rothschild and Turn-bull (1987) in their recent diagnosis of syphilis. We are also not sure how eflTective such methods would be in ourcase, that is, concerning nonspecificcontamination. For this reason and inthe spirit of the preceding proposal, wehave presented our case for discussionin the hope of finding a more concretebasis for our submitted diagnosis ofnoma. Skin and soft tissue samples areavailable upon request. However, dueto the limited quantity of research mate- rial, we reserve the right to select theapplicants correspondingly. AcknowledgmentsThe authors are indebted to Profs. E.Grosshans, Clinique Dermatologique,Strasbourg, and J. Maleville, Servicede Dermatologie, Centre Hospitaller etUniversitaire, Bordeaux, to D.H. Con- nor, M.D., Chairman of the Depart-ment of Infectious and ParasiticDiseases Pathology, Armed Forces In- stitute of Pathology, Washington, D.C.We also appreciate the help of M.Tomsky, Department of Dermatology,University of Tubingen, and S. Piiiibo,Department of Cell Research, Wallen-berg Laboratory, University of Upsala. Literature cited Braun-Falco, O., G. Plewing, and H.H.Wolff. 1984. Dermatologie iind Vene- rologie. Berlin: Springer- Verlag.Breasted, J.H. 1930. The Edwin Smith Sur-gical Papyrus, vol. I: HieroglyphicTransliteration, Translation and Com-mentary. Chicago: University of ChicagoPress.Connor, D.H., and R.C. Neafie. 1976.Tropical Ulcer In C. Binford and D.H.Connor, eds . . Pathology of Tropical andExtraordinary Diseases, vol. 1, 199-201. Washington, D.C: Armed ForcesInstitute of Pathology.Ebbell. B. 1939. Die alt-agyptische Chi- rurgie. Die chirurgischen Abschnilte derPapyrus E Smith und Papyrus Ebers.Skrifter utgitt av del Norske Videnskaps-Akademi i Oslo. If. Hist.-Filos. Klasse,No. 2.Grapow, H. 1956. Kranker. Krankheitenund Arzt. Berlin: Akademie-Verlag.Greive, J. 1756. A. Cornelius Celsus: OfMedicine. Translated with notes criticaland explanatory, in 8 books. Book 6.London . Haneveld, G.T 1974. An Egyptian Mum-my of the New Kingdom with an Ulcera-tion of the Leg. Archivum ChirurgicumNeerUmdicum . 26( 2 ) : 1 04- 1 07 . Joseph, S.W., and J.F. Duncan. 1976.Noma. In C. Binford and D.H. Connor,eds.. Pathology of Tropical and Extraor-dinary Diseases, vol. 1 . 202-204. Wash-ington DC: Armed Forces Institute ofPathology.Kalkofl". K . W. 1 98 1 . Tuberkulosc der Haul.In G.W. Korting, ed., Spezietle Der- matologie. Bd. II, 18.36-18.75. Stutt-gart, Germany: G. Thieme.Korting, G.W., and R. Dcnk. 1974. Der-matologische Diffcrentialdiagnose. Stutt-gart, Germany: Schattauer.Luger, A.F. 1981 . Syphilis, tiologie, Patho-genese, Klinik, Therapie und Pro-phyiaxe. In G.W. Korting. ed., SpezielleDermatologie. Bd. IV, 45.1-45.43.Stuttgart, Germany: G. Thieme.Maleville, J. 1976. La Syphilis et les Trep-onematosis Endemiques. DistributionGeographique ct Ecologie. Les Cahiersd'Outres-Mer. 113:7-17.Pahl, W.M. 1986. Tumors of Bone and SoftTissue in Ancient Egypt and Nubia: ASynopsis of the Detected Cases. Interna-tional Journal of Anthropology. 1:267-276.Patrick, A. 1967. Disease in Antiquity: An- cient Greece and Rome. In DR. Broth-well and AT. Sandison, eds.. Diseasesin Antiquity. A Suney of the Diseases.Injuries, and Surgery of Early Popula-tions. 238-246. Springfield, III: CharlesC Thomas.Rothschild, B.M., and W. Tumbull. 1987.Treponemal Infection in a PleistoceneBear. Nature. 329:61-62.Ruffer. M.A., and A.R. Ferguson. 1911.Notes on an Eruption Resembling That ofVariola in the Skin of a Mummy of theTwentieth Dynasty (1200-1100 B.C.).Journal of Pathology and Bacteriology,15:1-2.Sandison, A.T. 1967. Diseases of the Skin.In D.R. Brothwell and AT Sandison, eds.. Diseases in Antiquity: A Sun'ey ofthe Diseases. Injuries, and Surgery ofEarly Populations, 449-456. Spring-field, III.: Charles C Thomas.1972. Evidence of Infective Dis- ease. Journal of Human Evolution.1:213-224.Tempest, M.N. 1966. Cancrum Oris. Brit-ish Journal of Surgery. 53:949.Zimmerman, MR. 1977. The Mummies ofthe Tomb of Nebwenenef: Paleopathol-ogy and Archeology. Journal of theAmerican Research Center in Egypt,14:33-36.Summary of audience discussion: Someof the audience members questioned the na-ture of some histologic structures presented as lymphocytes, feeling their size and shapewould more probably suggest they are bac-teria. Zagreb Paleopathology Symp. 1988 Synthesis and conclusions Arthur C. Aufderheide and Donald J. Ortner Authors of the many excellent manuscripts presented at thissymposium were asked to include a special focus on eitherevaluation of extant support for traditional interpretations("current synthesis") or indentification of potential new areasof research or improved methods of doing current research("future options"). Both the depth and the breadth of their resjxjnse has been a source of special satisfaction to thisconference's organizers. The discussed topics can be viewedfrom several perspectives, including the following: I . In what ways can studies in paleopathology con-tribute TO AN understanding OF THE ORIGIN AND TRANS-MISSION OF DISEASES? Clearly, epidemiologic suggestionscan be derived from the simple establishment ofthe antiquityof a given disease. In their respective articles, Brothwelltraces measles to the Late Neolithic, and Manchester findsconvincing descriptions of tuberculosis as early as the fourthmillenium B.C. in Europe (Buikstra and Williams by at leastA.D. 700 in the New World) and leprosy in Egyptian bonesduring the second century B.C. (Andersen traces textual evi-dence to the third century A.D.). Using art sources Dequeckeridentifies rheumatoid arthritis in paintings nearly three cen-turies before its description by Sydenham in 1676. Gersztenand Allison moved back the search for histologically docu-mented primary cancer to a facial rhabdomyosarcoma in aSouth American mummy dated to about a.d. 500.An alternative approach is embodied in Brothwell's sug-gestion that zoonoses may reveal the evolutionary origin ofdiseases. He notes that domesticates may transmit diseases(cattle: tuberculosis; birds: ornithosis; cats, sheep and pigs:toxoplasmosis). Furthermore, the dairying activities of earlypastoralists exposed them to brucellosis, bovine tuberculo- sis, and a host of other conditions commonly resident in suchanimal populations. He suggests that the unravelling of para- site evolution could yield an unexpected harvest of informa-tion regarding hominid interactive behavior.Manchester's meticulous dissection of the chronology oftuberculosis and leprosy prevalence in England demonstrateshow paleopathology can provide data not retrievable by anyother current methods: disease interaction producing newdisease patterns. His study reveals how the crowded livingconditions of medieval urbanism fueled a rapid rise in pulmo-nary tuberculosis, generating a population who.se tuberculin- Zagreb l\ileopaihology Symp. 1988 positive immune status crossreacted with the leprosy bacillusto suppress expression of the latter disease (an observation ofpotential therapeutic value in areas of current leprosy en-demicity).Integration ofcultural information with physical evidencecan both define and become predictive of behavioral aspectsof disease susceptibility. Rose and Hartnady clearly spell outthe tragic relationship of high infant mortality and infectionsamong post-Reconstruction North American blacks and theirsocioeconomic misery with accompanying malnutrition.This process is mirrored also in Owsley's documentation ofdecreasing femur cortex thickness among midwestem NativeAmericans following contact, and in Goodman's demonstra-tion of dental hypoplasia in disadvantaged subgroups ofMexican children. Kelley also notes that the socially disrup-tive effect of a major epidemic on an isolated population can,together with other aspects of their life style, be sufficientlyprofound so as to account for the documented high preva-lence and mortality of such infections among Native Ameri-cans in the early colonial period without resort to a hypoth-esized inherent biological susceptibility greater than that ofimmigrating Caucasians.These observations can spawn a host of research studies:Manchester's reported disease relationships need to be inves-tigated in other locales, both archeological and in modem,living populations. Some of Brothwell's provocative sugges-tions can be tested with existing methods while evolvingtechnology such as viral DNA probes may become suffi-ciently sensitive so as to permit tracing specific virusesthrough past millenia. Goodman's research model seeks evi-dence that dental enamel defects refiect serious health prob-lems in a simultaneous study of both ancient and modempopulations. A similar approach could be applied to test theobservations of Kelley, Owsley, Rose and Hartnady, exploit-ing the fact that appropriately selected modem populationscan permit assessment of socioeconomic status, malnutritionand other effects of interest more precisely than is possible inan ancient skeletal population alone. 2. The above observations also provide a partial and posi-tive response to Pfciffer's question: Can paleopathologyBE predictive OF CONTEMPORARY HEALTH PATTERNS? andvice versa. She points out, however, that there are presently305 306 ? Arthur C. Aufderheide and Donald J. Ortner constraints inherent in the methods of paleopathology whichprevent such studies from contributing novel data. Principalamong these is the difficulty in defining the genetic homoge-neity of an ancient ptipulation when studying the geneticcomponent of a condition such as the "New World Syn-drome" among native North Americans. Now that DNA canbe extracted from archeological skeletal tissue and amplified(Tuross. pers. comm.) and with increasing availability ofDNA probes for the highly polymorphic HLA system, it isconceivable some of these constraints may be ameliorated. 3. The anatomists' contention of an intimate relation-ship BETWEEN STRUCTURE AND BIOLOGICAL FUNCTION innormal tissues applies equally todiseased ones. While admit-ting frequent difficulties, Stirland suggests that enthesiopa-thies, hypertrophic crests, and skeletal response to repetitivemicrotrauma can be used to identify occupationally inducedchanges in appropriately selected populations. Martin notesthe negative counterpart, pointing out that bone growth arrestsecondary to severe matabolic stress is reflected in histologicevidence of increased skeletal remodeling with decreasedcalcification. Microradiography and radiation absorptio-metric measurements of bone mineral density reflect similarchanges. Both grossly evident and electron microscopicalalterations are produced in the enamel of children's develop-ing teeth when such metabolic insults occur in a pediatricpopulation. Routine application of these methods, however, will become predictive at a useful and reliable level onlywhen sufficient human clinical, animal, and paleopathologi- cal research studies have defined the precise sensitivity andspecificity of these measures. 4. While paleopathology is often labeled a "young sci-ence," this symposium has revealed it is old enough to havedeveloped an area of vulnerability sufficiently serious tothreaten its potential for flourishing growth: lack of meth-odological STANDARDIZATION. Sincc most skeletal collec-tions are of small or modest size, prevalence data can only becomputed for many conditions by combining multiple, inde-pendent reports. If the authors of the many articles sopainstakingly reviewed by Gladykowska-Rzeczycka (docu-menting tumors in middle and eastern Europe) had all used astandardized reporting form which included a complete boneinventory and other vital data, then their value would havebeen considerably enhanced by making comparative, quan-titative estimates possible. Perhaps even more important isthe assumption that paleopathological taxonomy is equatablewith clinical disease classification, when in fact the observa-tional database of each is shared only in part with the other.The paleopathologist enjoys an unobstructed view of everybone in the skeleton, but lacks clinical symptomatology, softtissue biopsy and autopsy information as well as results ofchemical and metabolic studies. A significant contributionby this symposium is the unveiling of the need for an inves-tigative development of a classification of bone alterations based solely on paleopathological observations, and thentesting its utility by using it to develop a differential diagnosislist of diseases classified as clinical conditions.An additional threat to the intellectual health of this field isthe lack ofa general body oftheory, as noted in the introduc-tory section of this volume. 5. The paleopathology database which is traditionally gen-erated largely on the basis of gross skeletal structural featuresis now being enhanced by new and sometimes exoticSTUDY methods. Some of these promise to provide the typeof data that has been restricted to date to biochemical studiesof living individuals' blood samples. Imagine the informa-tional legacy of infectious disease history which could beharvested if Tuross's reported demonstration of immu-noglobulin in bone extract could be refined through furtherresearch into identification of bacteria-specific antibody! Inthe same manner, the first step in testing Angel's hypothesisof the interdependence of thalassemia and malaria in theMediterranean would become possible if Ascenzi's identi-fication of hemoglobin's globin chain structure could be es-tablished on a firm and reproducible basis. While less broad-ly applicable. Baud's and Kramar's studies dealing withcrystallographic structure of tissue calcifications alreadyhave some etiological predictive value, for example, thepresence of apatite and whitlockite predict a tuberculouscause of the calcifying lesion. Wider use of bone histology.both light microscopical and ultrastructural, would surelyidentify a broader range of features useful for its diagnosticapplications.Textual and artistic methods as reported here by Andersen,Chase, Dequecker, and Urteaga can make nonquantitativebut specific contributions in spite of their inherent limitationsof time and artistic license. Blackman et al.'s elegant recon-struction of a fatal sequence of renal pathophysiologicalevents was made possible by the study of anatomic andchemical changes in mummified soft tissues. Newer radi-ological methods, especially computerized tomography, canprovide information through uncluttered views of internalstructure (Lewin), supplemented by density informationwhich can be particularly helpful in studies of unwrappedhuman mummies. Investigations designed to determine />rf.r-ervation of the various proteins of diagnostic interest indifferent forms of mummification would be helpful(Aufderheides). Extraction of human DNA from an 8000-year-old brain by Hauswirth et al. promises exciting poten-tial, especially now that the polymerase chain reaction (PROcan amplify even the smallest quantities of recovered DNA tothe point of reactivity with diagnostic nuclear probes. Manytechnical difficulties remain to be overcome, not the least ofwhich constitutes concern for the degree of postmortem mo-lecular damage with loss or substitution of various bases.Nevertheless, research directed at overcoming these prob-lems is highly justified in view of the anticipated rich re-wards, such as diagnostic screening for genes coding for Ztj^rt'h Paleppathnlofiy Svm/}. I^HH Synthesis and conclusions ? 307 congenital disease conditions (cystic fibrosis, Huntington's,and others already available), ability to demonstrate closegenetic relationship through the HLA system, identificationof specific infectious pathogens (Mycobacterium tuber- culosis, Salmonella sp., Legionella) including retrovirusessuch as HIV and others. Completion of the present effort tomap the entire human genome can be expected to expandthese applications manyfold. All of these methods, however,are in their infancy. Collectively they will require an enor-mous amount of investigative effort before the contributionsof their application have been defined at a useful level. 6. This symposium has also identified new evidence (or critically reviewed existing evidence) which suggests alter-natives TO THE TRADITIONAL VIEWS OF PATHOGENESIS for a variety of conditions. Stuart-Macadam identifies multipleobservations inconsistent with the concept of porotic hyper-ostosis as a product of congenital anemia. She reminds usthat a departure from the norm may be adaptive, when shepoints out the iron-deficiency anemia so common in milk-fedinfants may have a protective effect against bacterial infec-tions. While not denying the role of malnutrition in the pro-duction of certain dental enamel defects, both Dahlberg aswell as Kocsis and Marcsik note that developmental defectsmay be responsible for others. Studies are needed to establishclear separation of these two, divergent pathogenetic mecha-nisms if interpretational confusion is to be avoided. Vyhnanekand Stioukal also note that accumulating evidence relating tothe biological behavior of transverse (Harris' ) lines of bonegrowth arrest needs to be refined and incorporated into ourinterpretative process if we are to escape errors inherent inthe relatively simplistic application common for this methodto date. Kelley's postulate that environmental, not genetic,factors can explain the high frequency and mortality of cer-tain infectious diseases among native North Americans alsoshould be tested. This need not necessarily await develop-ment of sophisticated methods of DNA analysis. Clinicaltuberculosis treatment records already exist which, if appro-priately selected and studied, may be capable of identifyingwhether or not Native American tissue and immune re-sponses to both the disease and treatment differ from thoseof Caucasians. Coupled with detailed epidemiological stud-ies a database useful in evaluating this question may be pos- sible.Urteaga warns that the nasal destructive changes attributedto leprosy in Europe may be lacking in Amazonian lepers,and that such changes in the latter region can be duplicated byleishmaniasis. Brothwcll notes the high probability that bru- cellosis was present among early European pastoralists andargues the need for studies which would define patterns of skeletal changes diagnostic for this disease, which could thenbe employed for its recognition in archeological skeletons.Roberts makes a good argument for her complaint that thephysical evidence of trauma contains much more informa-tion than is usually derived from it by conventional studies. Zagreb Paltopalhology Symp. 1988 Her interdisciplinary approach appears to offer anthropo-logically useful information not only for reconstruction ofcircumstances leading to the injury and of treatment admin-istered, but also for prediction of specific fomis of subse-quent dysfunction caused by the lesions.While the references to tuberculosis by many symposiumauthors have been recorded above in other contexts, it may beuseful to concentrate these concerns within this discussion.Buikstra and Williams's simulation studies suggest the dis-ease should not have survived in North America under theconditions of their study and stipulations. It would be usefulto repeat these, probably for different locales at differentperiods. Their suggestion that alternative organisms mayproduce identical skeletal changes may be testable with mod-em laboratory animal studies and perhaps in ancient skeletaltissue after some of the newer diagnostic methods (molecularbiology?) discussed above become available. Such methodsmight also lend themselves very well to pursue the patho-genic role played by atypical mycobacteria although usefulinformation could already be derived from thorough currentenvironmental studies with conventional methodology. The ultimate availability of reliable nuclear probes for the variousmycobacterial species and variants can be expected to permitstudies directed at Brothwell's question whether M. tuber-culosis was derivedfrom the avian or bovine strain. In trac-ing the antiquity of tuberculosis such methods applied to theearlier examples of Egyptian skeletal lesions (Morse et al.1964) would also be useful, as well as those of the SouthAmerican mummies (Allison et al. 1973). Kelley andMicozzi's 1984 assertion that localized rib periostitis reflectstuberculous empyema needs to be verified, most easily inmummies where empyemas of both tuberculous and non-tuberculous nature occur. Not only do Manchester's noteddisease patterns resulting from interaction between tuber-culosis and leprosy need to be checked in other geographicalareas, but it would be useful also to design investigations forthe evaluation of his assumption that during the Early MiddleAges gastrointestinal tuberculosis affected both village andurban areas equally because it was dependent upon herd, nothuman population size.Paleopathologists have also been criticized for their reluc-tance to integrate their data with that generated by medicalhistorians. Occasional examples exist which demonstrate itspotential usefulness (Handler et al. 1986). and it is not diffi- cult to visualize other possibilities. In summary, these presentations succeed in achieving thesymposium's goals: "Current synthesis and future options."The ultimate adoption of even a fraction of the new methodsdiscussed can be expected to change the nature of pal-eopathologic study more during the coming decade than ithas enjoyed during the past century. The editors hope pub-lication of these manuscripts will serve as a useful guide andstimulant to future paleopathology investigations. 308 ? Arthur C. Aufderheide and Donald J. Ortner Literature cited Allison, M.J., D. Mendoza. and A. Pezzia. 1973. Documentationof a Case of Tuberculosis in Pre-Columbian America. AmericanReview of Respiratory Disease. 107:985-991 . Handler. J.S., A.C. Aufderheide, R.S. Corruccini, E.M. Brandon,and L.E. Wittmers Jr. 1986. Lead Contact and Poisoning inBarbados Slaves: Historical, Chemical and Biological Evidence.Social Science History. 1 0: 399-425 . Kelley, M.A., and M.S. Micozzi. 1984. Rib Lesions in ChronicPulmonary Tuberculosis. American Journal of Physical An-thropology 65:381-386.Morse, D., D.R. Brothwell, and P.J. Ucko. 1964. Tuberculosis inAncient Egypt. American Review of Respirator^' Disease. 90:524-541. Zagreb Paleopathology Symp 1988 Participants Marvin J. AllisonMedical College of VirginiaRichmond, VA 23298 Johs G. AndersenBraincparken 85. st. th.,DK-6100 Haderslev. Denmark A.J.G. AraujoNational School of Public HealthOswaldo Cruz FoundationRio de Janeiro, Brazil Antonio AscenziDipartimento di Biopatologia UmanaSezione di Anatomia PatologicaUniversita "La Sapienza"Policlinico Umberto IViale Regina Elena 3241-00161 Rome, Italy Arthur C. AufderheideDepartment of PathologyUniversity of Minnesota-DuluthSchool of MedicineDuluth,MN 55812 Mary L, AufderheidePaleobiology LaboratoryUniversity of Minnesota-DuluthSchool of MedicineDuluth, MN 55812 C.-A. BaudUniversite de GeneveDepartment D'Anthropologie12, Rue Gustave-Revilliod1227 Carouge-Geneve, Switzerland Pia BennikeInstitute of Medical Anatomy BUniversity of CopenhagenBlegdamsvej 3DK-2200 Copenhagen N, Denmark James BlackmanAssociate DirectorFamily Practice Residency Program777 North Raymond St.Boise, ID 83704 Don R. BrothwellInstitute of ArchaeologyUniversity of London3 1 -34 Gordon SquareLondon, WCIH OPY, England M. BrunoriDip. di Scienze BiochimicheUniversita "La Sapienza"Rome, Italy Jane E. BuikstraDepartment of AnthropologyUniversity of Chicago1126 E. 59th St.Chicago, IL 60637 M. ChameNational School of Public HealthRio de Janeiro. Brazil Debra A. ChaseDepartment of Near Eastern Languages& CivilizationsHarvard UniversityCambridge. MA 02138 Ulisses E.C. ConfalonieriNational School of Public HealthOswaldo Cruz FoundationRio de Janeiro. Brazil Albert A. DahlbergDepartment of AnthropologyZoller Memorial Dental ClinicUniversity of ChicagoChicago. IL 60637 Jan DequekerArthritis and Metabolic Bone DiseaseResearch UnitK.U. Leuven. U.Z. PellenbergB-3041 Pellenberg. Belgium Cynthia D. DickelDepartment of Immunology and MedicalMicrobiologyBox J-266 JHMHCCollege of Medicine. University of FloridaGainesville. FL 32610 David N. DickelDepartment of AnthropologyFlorida State UniversityTallahassee, FL 32306 Glen H. DoranDepartment of AnthropologyFlorida State UniversityTallahassee, FL 32306 Howard DuncanDivision of RheumatologyHenry Ford HospitalDetroit, Ml 48202 A. BellelliDip. di Scienze BitKhimicheUniversity "La Sapienza"Rome, Italy G. Citroinstituto Regina Elena per lo Studioe la Cura dei TbmoriRome, Italy L.F. FerreiraNational School of Public HealthOswaldo Cruz FoundationRio de Janeiro, Brazil Zagreb Pateopathology Symp. 1988 309 310 ? Participants Enrique GersztenDepartment of Pathology. Box 662 _ Medical College of Virginia ' Richmond. VA 23298 Judyta Gladykowska-RzeczyckaDepartment of AnatomyAcademy of Physical Education ul. Wiejska 180-336 Gdansk. Poland Alan H. GoodmanSchool of Natural SciencesHampshire CollegeAmherst. MA 01002 Philip HartnadyDepartment of AnthropologyUniversity of ArkansasFayetteville. AR 72707 William W. HauswirthDepartment of Immunology and MedicalMicrobiologyBox J-266 JHMHCCollege of Medicine. Universityof FloridaGainesville, FL 32610 R. IppolitiDip. di Scienze BiochimicheUniversita "La Sapienza"Rome. Italy Robert D. JurmainDepartment of AnthropologySan Jose Stale University125 .South Seventh St.San Jose. CA 95192 Marc A. KelleyPaleobiology LaboratoryUniversity of Minnesota-DuluthSchool of MedicineDuluth. MN 55812 Gabor KocsisDepartment of Dentistry and Oral SurgeryAlbert Szent-Gyorgyi UniversityMedical School6701 -Szeged, Hungary Philip J. LaipisDepartment of Biochemistryand Molecular BiologyBox J-245 JHMHCCollege of Medicine. Universityof FloridaGainesville, FL 32610 James C.C. LeisenDivision of RheumatologyHenry Ford Hospital2799 W.Grand Blvd.Detroit, Ml 48202 E. LendaroDip. di Scienze BiochimicheUniversita "La Sapienza"Rome. Italy Peter K. LewinHospital for Sick Children555 University Ave.Toronto. Ontario. M5G 1X8, Canada Keith ManchesterUndergraduate School of Studiesin Archaeological SciencesUniversity of BradfordBradford West Yorkshire BD7 I DP,England Antonia MarcsikDepartment of AnthropologyAttila Jozsef UniversityP.O. Box 586Egyetem-u. 2670 1 -Szeged, Hungary Debra L. MartinSchool of Natural ScienceHampshire CollegeAmherst. MA 01002 Juan R. MunizagaUniversidad de ChileSantiago. Chile Norman OldroydLaboratory SupervisorLouis C. Herring and CompanyOrlando. FL 32802 Douglas W. OwsleyDepartment of AnthropologyNational Museum of Natural HistorySmithsonian InstitutionWashington, DC. 20560 Wolfgang Michael PahlInstitut fiir Anthropologicund HumangcnetikUnivcrsitat TubingenWilhelmstr 27, 7400 TijbingenWest Germany Susan Pfeitt'erSchool of Human BiologyUniversity of GuelphGuclph. Ontario NIG IWI. Canada Mary Lucas PowellMuseum of AnthropologyUniversity of KentuckyLexington. KY 40506-0024 Graeme L. PrettySouth Australian MuseumAdelaide, Australia Miroslav ProkopecInstitute of Hygiene and EpidemiologyPrague. Czechoslovakia B.M. Ribeiro FilhoNational School of Public HealthOswaldo Cruz FoundationRio dc Janeiro. Brazil J.M. RiddleDivision of RheumatologyHenry Ford HospitalDetroit. Ml 48202 Charlotte RobertsSchool of Archaeological SciencesUniversity of BradfordBradford West Yorkshire BD7 I DP.England Jerome C. RoseDepartment of AnthropologyUniversity of ArkansasFayetteville. AR 72701 Christiane KramarDepartement d 'Anthropologic12 rue Guslave-Revilliod1227 Carougc-Gencve. Switzerland Donald J. OrtncrDepartment of AnthropologyNational Museum of Natural HistorySmithsonian InstitutionWashington. D.C. 20.560 R. Ted SteinbockX-Ray Associates of LouisvilleSuite 1 17. Mall Office Building400 Shcrbum LaneLouisville. KY 40207 Zagrvh Paleopathology Symp. 1988 Participants ? 311 Ann StirlandUniversity College. LondonThe Cottage, Lower Green. Woodend,Towcester, Northants NN12 8SB. England Milan StloukalDepartment of AnthropologyNational MuseumPrague, Czechoslovakia Eugen StrouhalNaprstek MuseumSection of the National MuseumBetlemske n. I . 1 1000 Prague I . Czechoslovakia Patty .Stuart-MacadamDepartment of AnthropologyUniversity of TorontoToronto, Ontario M5S lAI, Canada James M. TenneyResearch AssociateLowie Museum of AnthropologyBerkeley, CA 94720 Noreen TurossConservation Analytical LaboratorySmithsonian InstitutionSuitland, MD 20746 Oscar Urtcaga-BallonApartment 905 1 1 Island AvenueMiami Beach. FL 33139 W. UndeutschHautklinik der Universitat TubingenHistologisches LaborLiebermeisterstr. 25, 7400 TubingenWest Germany Sloan WilliamsLos Alamos National LaboratoryLife Sciences DivisionBox 1663Los Alamos, NM 87545 Joseph ZiasIsrael Department of Antiquitiesand MuseumsJerusalem, Israel R. ZitoInstituto Regina Elena per lo Studioe la Cura dei TumoriRome, Italy Takao SuzukiDepartment of EpidemiologyTokyo Metropolitan Instituteof Gerontology35-2 Sakae-cho, Itabashi-kuTokyo 173, Japan Lubos VyhnanekRadiological ClinicMedical FacultyCharles UniversityU nemocnice 2128 08 Praha 2, Czechoslovakia Zagreb Paleopathology Symp. 1988 JJAN INSTITUTION 3 9088 00911 7060 :^:i ";*'.:' 'iS jJif :;;- >:vM ?' n :mm !'.' i-.'>^,''^'"K^ 3:sfiiN i-shQ'i/h