The Cambridge Encyclopedia of Human Paleopathology Arthur C. Aufderheide & Conrado Rodriguez-Martin including a dental chapter by Odin Langsjoen 2 CAMBRIDGE |) UNIVERSITY PRESSGlb.0> Asoo Jon. The Pie Blog rmpogon Set, Chg, Ute Kingdon The Baugh Bang, Camb C2 2A UK Yr 2 Soe, New ok NF 11-211, {$77 inne sd For Malo, IC 3207 Aa ae de An (2, 20014 Mad, pin oct Hou Toe Werf, Cpe Toe 801, eh Ate aps ewcambige cng (© Cambs Unie e198 “Wea apa Ste my eon sd ote pref enn oleae Waning re, sormprdion oy prt my ap ot tren ion oan Une Pe. 192723 pli 1998 oe mn 006 ‘Prine nthe Une angie at tey Re Combe ‘Typos 10.25/15 pe Qube Ache nl bri elo ee ey ete Abr ‘Mee Cambie neyo of bun ppl Aur ¢ Alea ‘conrad Reiger Mart: nating dal char yO Lange, luce togpe reece ad nde 0 $24 #52016 Ganda) 1, Plopaoigy ~aeelepetis 1 Reiguen ann, Cord LLngpeen Ol, 1925 ETA, (BN 1 Pepalgy crops QE AME 197] eisar-aa) 97-1603 fer uray ofconges |W 0 521552036 adcContents face w ‘Acknowledgements mi Pant One History of paleopathology + Introduction “Antecedent phase (Renalssanceto mid-nineteenth century) 2 ‘Genesis of aleopathology (mid-nineteenth century to World War) 3 Interbellum consolidation phase (World War toWorld wari) 5 ‘Thenew paleopathology (World Wari uptothe present) 7 y4 Mare Armand Ruffer Parr Two Pseudopathology 1 Introduction 12 Soft tissue pseudopathology 12 Pseudopathologicaeaurs related to mortuoy practices 12 Pseudopethology resulting from efecsarsing within body assue allewing interment 34 changes arsng from eects ofthe interment environment 15 ‘Skeletal tissue pseudopaleopathology 15 ‘xcovtionskeletlartfacts 35 ostexcavation specimen handing 35 Scavengerandinsetefects 15 Botanical eects 36 Cyogenicand hermaleffectsonbone 16 hema ersion 16 ‘Mirobilogicalagents 36 Prssureofets 17 Radoogicalpeeudopathology 17 Parr THREE ‘Traumatic conditions .» Skelotalevidenceoftrauma 20 ‘Slulfntres nd rushing injures 23vill | conrents: Vertebrotandthorcifrocures 24 Discos 25, Troumaiemysisossians 26 Located subperstel thickenings 27 ‘Skeletal injures by weapons. 27, Decoptaion 29 ‘Sangulation “29 ‘Amputation: the skeletal evidence 29 ‘amputation: the sop tissue Inge) euidence 30 Tephinaion 32 Genial deformation 24 Cautereaion 36 loodleting 36 Seaping 37 Cnetion "38 Soft tssueinjuries: inflicted bythers. 38, ocerotins ond stab wounds 38 Seeiiceviins 42 ‘ecientlinjries 44 Soft tissue injuries: mutilation 45 abrets 45, Nesalandearings 45 Nairn ais 46 Crcumcsion 46 Tattoasandscarfcation 47 Part Four Congenital anomalies 5: Congenital skeletal anomolies 52 ‘Skull malformations 52 Crniosmostoses 52 Conplexcrnojcialdefrmiies 54 ‘Anencephaly 55 ‘Micocephay 36 ‘Mocrocephaly 57 rrocepelus 57 Congentalhemlationofmeninges and rain 58 eftpaltepalatascis) 58 Enlarged prea framin (oramina parietal permagna: atin tia) 59 CCongesitalmalformationsofthespine 59 ‘les ocptalitin atlano-ocptl fusion; tlonto-ccptl ‘ssiiatin) 59 Basarimpression 59 Kippel-Fetsyrdrome 60 Jartho-Levin syndrome of vertebral aromas 60 Congentalabsenceoftheadontoidprocess. 6 Spinabiide 6 Buteryverebe 62 ‘Anterior spinatipda. 62 Incampete segmentation of etebresegments 62 Spondyfolyisandspondyllsthesis 63 liemiverteoroe 64 Socrococeygealagenesis 64 Soorlageresis 64 Congenital absence ofthe pedicles 65 Tronsonalveretnoe 6 Scola 66 Congentalryposs 68 Congenital malformations ofthethorax 68 Cereals 68 Costalfsion 69 Otherrb anomalies 69 Congenital malformations ofthe pelvis 6 Congentadslocation ofthe hp 69 soy ofbladderandcie pels 70 ‘Aplasiaand hypoplasia oftheextremties 72 Falturesinthedevelopmentayaline 70 Folluresin the developmentofbones 73 Upperextremity malformations. 72 Dysostsiscleldocanials 72 Sprengel deformity 72 Madelung scefornity 72 Congenitalradioutnarsynostosis 73 Congenital dsacation of teradus "73 Congentalpseudoarvassofthe clave 73 Carpatbiocks 74 Lower extremity malformations 74 ‘Developmentalcoravara 74 ‘enurecuratumcongentum 74 Biparitepatefla 74 Congenitalonguation of he bie 74 Congenalpseudoartvassofthe bie 74 Tia oularsynostosis 75 Tarsolbiocs 75 Tales equlnvanss 75 Metatorsusvaruscongentus 76 Talusveriatscongentus 78 ‘Malformations ofingersand toes 76 ‘Adin 76 Sydecty’ 76 Potydacny 76 Sympbalengism 76 Hyperoboingism 76 Pant Five Circulatory disorders 77 Aneurysms 78 "Aheroscleoi peripheral asculerdseaseandaneuysin mation 72 Infeciousareurysn 79 ‘aural ose9 aneurysms 80 Jortiessction 80 Congenital artic disease 20 ‘Coartationftheoorta 80 Paleopehotogyafaneunsms 8 ‘osteochondritis dissecans —& ‘Syonymyanddefnition 81 ‘Blologyend epidemiology 8: Pathogenesis” 82 Radiology 83 ‘Conpiatons 3 Paleopthotogy 83 Osteochondroses 83 eg9-Calé-Perthesdiease 84 Osgood-Schatersdsease 85, Sindng-ohansson-Lasensclstose 85 Blounctsease 85 Osteochondasisof te proximal epiphysis 86 Necrosisofésolobat epiphysis 86 Haglund asease 86 ‘Kohiers disease 86 Frebersdiseae 86 Eppbysisof te fst proximal phalancafthefoot 87 ‘Sehauemann’s disease 8 Calves disease 87 Pamersdsease 87 Kienbéeksdisene 88 Prisersdisease 88 Thlemanns disease 89 VenWeckscseose 9 Necrosis ofthe femoral head 9 ‘Synonymy andepliemblogy 89 Pathogenesis andradiciogy %Paleopethology 89 Primary necrosis ofthe media femoral condyle. 89 Foldeioiogyandetilogy 89 Patholoay 89 ‘Slipped femoral capital epiphysis 90 Defaton epidemiology andeoiogy 90 Pathology end complications 90 Paleopatblogy 90 Hypertrophic osteoarthropathy 91 Defation andepldemiology 9 Patotogy 9 Radiologealfeatues 9% Diferentaldagnosis 9: Praleopathology 91 Parr Six Joint diseases 93 Degenerativejoint disease 93 ‘Defniton epidemiology andetilogy 93 Patbolgy ond radiology 94 Paleopathelogy 95 Degenerative disease ofthespine 96 Defridon endepidemioiogy 96 Patbolsy 96 Palopattotony 97 Dis idiopathic skeletal hyperostosis (DISH) 97 ‘Defcon etiology andepidemiology 97 Pathelogyand radiology 97 Differential iegnosi Between DISH and ankylosing sponds 98 Palepetnoiony 98 orn DISH 99 Rheumatald arthritis 99 Defirtonetlogy and epidemiology 9 Netaral histo 99 Paleopathoiogy "100 Jwesile chronic arthritis x01 Defntion,etziogy end epdemiotooy 10% Pathology radiology and natural history 10% Peleopathology 302 Ankylosing spondyitis (AS) 02 Defation. etiology andepiemology 102 Pathology railogy and naturaistory 102 Poleopathology 303 Psoriaticarthtis 104 Defnton etiology and epléemoiogy 104 Pathologyend radiology "304 Paleopathology 04 Reiter's syndrome (eactivearthrts) 104 Definition etiology andepiemioiogy 104 Pathology ralogy and natura history 104 Paleopathelogy 105, Enteropathicarthropathies. 105 Traumaticartheis 105 Defntion and pathology 105 Paleopathology 105, Nonspeciicseptic arthritis 06 Definition elegy ond epidemiology 106 Pathologyendradioiogy 106 Paleopathotogy 107, Neurotrophic arthropathy 107 Defnton elegy pathology and epidemitogy 307 Palepettotogyofharotsjaine 108 Gout 308 Defnton andetilogy 108 Epidemiology 308 tural history 208 ‘atityanchistory 220 Skeletalpathology 310 Paleopathloay 1 Cochronasis 11 Defnton epidemiology etiology and neal istony 3 Pathology of skeletalandsofssuelesions 331 ‘Anca histor, end peeopathology 122 Hemochromatosis 113 Defer 33, Genet eriman, heredltny eopathie hemochromatesls 133 Aewureshemoehomatests 13 Paleopattology 14 Calcium pyrophosphate deposition disease (pseudogout) 114 Definton etiology andepldemicogy 14 Pathology endradology 34 Difernialciegasis 14 Joint sarcoldosis 114 Osteltiscondensasilil 14 Amyloldesis 35, Joint neoplasms 315, Pigmentedvilenodvlersyovis 115 Syrovalosteochonaromatasis 335 ‘Synavlalhemangiome 335 Symoviaisonoma 336 Part SEVEN Infectious diseases x7 Bacremiatinrecrions 18 Tuberculosis 338 Defnition ondtaxonomy 118 Pathogenessand naturaistory 19 Epldemoiogy entity and histo 325 Features ofspecial bioantropologcalinteest 331 Poeopathologialappeornce oflesions 133 Differential ciagnosisoftuberculsieIkelesions 140 Leprosy sai Defation ondtavonomy 148 Epliemology 242 Immunologzl modulations oflpresy infections 143, Nawwratisory 44 Imveractons between eprosyand tuberculosis 146 inal course 147 ‘atiutyandistory 247 Steletlpethology 150 Paleopatralogy 354 Treponematosis 54 Defnionandtexorony 354 Phta 355 awe 355 Bejet_ 157 Venerealsyphite 357 Congenital syphilis 164 ‘Origins ofthe vepenematoses x66 Geogephicaigins ofthe weponematoses 67 Histor fthetreponematases 168 Palepetrologtaleviencecfsyphits 169 Osteomyelitis 172 ‘Acta osteomyeltts 372 ‘one pyagenicosteomyelts 377 Brodlsanscess 178, ‘Sclerosing osteomyelitis of Gore 378 Septic artis 378 Perosite 379 Poleopthologicalevdence 379 Pneumonia <5: ‘efintn andepidemiology 381 Netualison) 182Aotiutyend history 185 Implications forancient populations 186 Softssvelesins in oncent human remains 387 Salmonellosis 190 Definition epidemiology axanomyand gecgrphy 190 Neturl history oftphotd fever 350 -Aatiqlty and history oftyphod fever 393 ‘Skeletal pathology ofrpholdfever 198 Brucellosis 292 Defriton taxonomy and geogrephy 392 History 192 Epidemiology and neta history 92 ‘Skeltapathotogy 192 Poleopathalogy 193, Adtinomycosis 193 Definition, toxonomy.andepidemitogy 193 ‘Natural history and skeletal pathology 394 Paleopthologicalevdence 295 Nocardosis 195, Defatan, raxonomy, epidemiology andetnicl features 195 Softssuandskeletlpatholegy 195 Plague 195 Defnon andtaxonony 195 Epidemiology 295 Natural nstary 196 Historyand antiquity 198 Poleopethelogy 198 Cholera 198, Gasgangrene 198 lymedisease 99 landers 299 Topical ulcer 200 Definition epidemiology and clinical features 200 Skeletal pathology and diferente agnosis 200, ‘inh 300 Virus inrecrions 200 Introduction 200 ‘Smallpox. 201 Defton and taxonomy 20% Epidemiology 208 Nowra history 202 History and prehistory 204 Severity 205 ‘istoryofsmalpoxpreventioneforts 206 Tisuelesions ofsmallpoxinancien¢ human remains 207 Measies 207 Definition taxonomy, andepldemllogy 207 Neturalhistoy 208 Complcaions 208 History 208, Paleopetralogy 209 Rubella 209 Defnton taxonomy geography epidemiology and natural history 209 ‘Skeletalpathology 280 Influenza 210 Deftiontaxonamyendepderioiegy 230 ‘natural istoy 238 Complications 211 story an. Impact of influent infection on ancen populations 212 Poliomyelitis 212 Miscellaneous virusinfetions 212 Funoacimrecrions 212 Introduction 212 History ofthe fungal infections 213 ‘Systemiemycoses 214 Blastomycasis 214 Definition taxonomy and geographical estibution 214 Epidemiology andneturalhistary 234 Steltapetiogy 24 fotgy 25 Paleopetotoy 25 Cacididonyensis 25, Defi, onan, andgegrphaldstibuson 235, Epierilgr and dealers 28, Stee geoiogy 26 Peleopatelogc eden 217 Wstoplasmosin 27 Dehlon erro epiemictonn andlor 237 Stetotnd sop tssvepattay 217 coyplocacanis 38 ‘Deft eonony ndenieniiany 238 Stetelondsop sue pathology 28 Paracocidndomyconis 38 Texromy ptenbig nd ste etaiagy 238 Stet penoiogy 29 Feleopatolgy 29 Candas 239 Taxarompandeideidbay 29 | Stetotpcthokay’ i ssperaioss 29 | ‘xray plemintgn ondstatlpatolay 9 | Macomyeosis 220 Texoma elenilogs.onseetlpatholay 220 Subctaneousmyeares 320 Sportichoss 520 Taxononrendepiteriiogy 220 Steel pooigy 238 Madwomyeass 2: Toaromyendgeorenhy 2: Fplemiolgy and inca fetes 222 Stektlpctology 292 Parasimcinrtcnons "222 Protoran infections 224 Amebiasis 224 Defienrdepiericlny 224 fet 350 Ania ond sory 225 iasmosis 236 eon tonomeandgeogupieldsbuton 236 Ecmilogy adnan. 238 Hon 236 Polepataosy 226 Chagas disease 227 Teroromyeptemiatgyandoaualistory 237 Gog diese noniquny 8 Malaria 226 Deftionxonomgeidemleax ond aeeophy 228 Natty 235 Intnctons Senet nla andresloodclpimorphisms 234 ‘gat anc ison 233 Impact oimoloia nonce peptone 237 Softtsstelsonsofmaoamancen human sues 237 otminh nections 258 Aacrais 238 ‘mromomgeptienology annua history 238 Ascari 39 Hooton "239 "eronomycedemblogg and tua tony 239 teotwom nant 339 Flariasis 240 Taxonomyepdenislagyondnatuastory 240 Fires mony eo Cestodes tapeworms) 240 Teeniasolum 240 Terran eensiogyendnanahtny 240 Teeiastumaneconnsiaay 24 Echinocoeiasis 242Taxonomy andepideniiogy 243 Uiecyele nd atura history 243 Pathalogy 242 ‘tuted paleopattology 243 Diferentaalagrosisofhydatiseyst 243 romatodes Mukes) 240 Paragonimiasis 243 Taxonomy epidemiology and natraistory 244 riiatyendpalepattoogy 245 Fascloiasis 245 Fasciolopsiasis 245, Clonorciasis 245 Ectoparastes 245 Pedicuosis 245 Typus 246 Pedislsisinaniguty 246 ParTEIGHT Diseases of the viscera 247 Introduction 247 Factorsinfluencingpreseration 247 Veriabl response ofbody tissues 248 Recogntion of morpholgicaltraons by disease 248 Topiscovered 248 Soft tissue lesions ofthe head and neck 248 Thebralnand meninges 248 Softissuelesionsoftheeye 251 Softssuelesonsoftheear 253 Softssuelesinsoftrenose 256 Softisselesions of heneck 259 Heart and pericardial diseases 259 ‘orenay trombosis nd nforcton 260 Injections 260 Velvlarheor asease 260 eareczeose ito miscellaneous causes 26: Palepetrolgyofcartiac pathology 261 Pulmonary diseases 262 ‘Cangenltalcondtlons 262 Pulmenaryinfctions 262 Degeneraivecondions 263 Vosulorcndnions 266 Neoplasms» 267 Farlgn bodies 268 Liver and biliary tract diseases 268 Prserationandappearance 268 Hepatitis 268: Cintas 269 Fatty degeneration ofthe er 269 Congentallesions 270 Gesgangrenesepticemia 270 ‘bscesses 270 Neoplasms 271 Bir trat eases 272 isceloneousconstons 273, Gastrointestinal tract diseases 273, Congentllesions 273 Ulertve gastrointestinal isons. 276 Imestnl obstruction 277 Infectious conditions 278 Neoplasms 279 Miscellncouslesions 280 Urinary diseases 281 Congentaesions 282 Infectious conditions 28% ydonephaosis 282 Glomeruonephis 283 Metabole conditions 284 Uypertensionandlabetes malitus 286 Meopasns 287 Genital diseases 237 Yresevatonofexemalgentallo 287 Senualtansmited doses 288 Tests 285 Prosote 289 ‘Abvonnaiiesoffemaentralgentaio 290 Dregnancyrelatedcontons 293) Breastdiseases 296 Novmal 296 lnfeciouslesions 297 Forocystceseese ofthe beast 297 Neoplasmsofthe breast 298 Gymecomasio 299 Poleopatolagical aspects ofthe breast 299 Dermatological diseases 302 Preservation 302 TTeumaiedermotlogcllesions 303 Infectious dermatologieallesions 303 Metabolic dermatologicoieions 303, Demetoiogica neoplasms 303 isceleneousconditons 304 Parr NINE Metabolic diseases 305 ‘Vitamin -tlated syndromes: rickets and osteom: Definition and epidemiology 305 amin meteboliem 308 amin Daction 306 fectsofdeieney 306 (ousesofuitamin Ddefency 308 DOsteomaiocia 309 ‘ntgutyard history ofickets 309 Paleopetnoiogyofickets 309 Scurry 310 Deftion ndchemical mechanism 320 Fldemology and nawralhistory 320 ‘Ancgutyond story 332 Paleopathology ond lferento diagnos" 313 ‘Osteoporesis 314 Defakionetclogy and epidemiology 324 Sheetal pathology 315 ‘Antu isan, ond pleopatology 316 Iwronicarions 316 Fuorosis 316 Defton etiology and epideriiogy 36 Pathophylologyofdentalfuoreis 317 ‘Skeletal petology in uoresis 337 Netual history offuoresis 387 Palepattologyoffuorsis 317 Lead poisoning 3:8 ‘Metolc and physiological features oflead 318 Histonfleadpesoning 318 Paleoptrologyoflead poisoning 319 Mercury poisoning 320 ‘xpasire 320 Taney ofmerury 320 Paeopatatagyofmereurypotoning 320 ‘senicpolsoning 321 Exposure 328 Metabolcaspects ofaseic 321 Tanleffectsofasenie 321 story and paleopaology of arsenicpoisoning 322 is 323 Paleopathloay 323 305vil | contents Part TEN Endocrine disorders 325 ‘The pituitary gland 326 Gigs 326, ‘cromegaly 327, Pitan everson 328 The parathyroidglands 330 Prmarybyperartbyidism 330 Secondo hyperaathyrldism 332 ypopaatnyriasm 333, Prsuthypopacthyealdem 333 Disorders affecting gender expression 334 Metabolic cousesofaberantgentalsiuciues 334 Genetic caus of aberrant gent structures 334, Thethyroid 334 "Thyroid strate and function 334 Graves disease 338 Thyoiis 335 Neoplasms 336 Solter 336 ‘Skeletallesionsin states of hyo dysfimeion 338 ‘Theadrenals 340 Noralacrealfuntion 340 ‘Aautearenalinsfcency: Waterhouse-Fiderchsensynarome 340, Chronic arent coral isuflency 340 Adrenal hyperinction 343 Diabetes mottus 343 Pathophysiology 348 Eidemology and tistory 343, Poleapathology 243 Pant Eteven Hematological disorders ays Disorders of ed blood cells (anemias) 345, Biology fred blood els production fncion, and destution 345 ‘Anemitsdietobloodio=s 346, ‘Anemia duetodecrecsedhemoglbnsythesls 348 ‘anemias duet increased red blood eldestrcton(remolyss) 348, Portichyperesosisandcibaorbtala 348 Disorders of white blood alls 352 Plsmacel scales 351 Histiocnosisx 354 Leukemia 355 Myers 355 Lymphomas 355 Sjstemiemastonyosis 356 Bleeding disorders 356 pmophio 356 Pant Twelve Skeletal dysplasias 357 Introduction 357 ‘Growth defects of ong bones ‘Achondoplesia 358 Croncrogysplslepancate 360 Camptomelic Dysplasia 360 ‘Mutipe enphysel dysplasia 362 ‘Shor-limbed évarfism with prominent spinealterations 36: Congenital spondyoepipyseal dysplasia. 36% Kelestdyspasi "361 larsen'smarome 361 spine 358 ‘Metaphyseal and dlephyseal disorders 36: Digphysealacass 361 ‘Metaphysealchondrodysplasia 362 ‘Metatrophie dysplasia 362 Dystophicdysplsia 362 Dyschendsteoss 362 Chondrectodermel dysplasia 362 Developmental anomalies of cartilaginous and fibrous components of theskeleton 362 Dyschondroplasla 362 Disorders of diaphyseal density ormetaphyseal remodeling 363, Osteoperosis 363 Dysocteocelease 363 Prknodysostasis 363 Infante coral yperstoss 363 Diaphyseal dysplasia 364 Frontometopysealdysplela 364 aniometophyseel dysplesio 364 Metaphysealayspasio 364 Crniodaphysel dsplesia 364 Meloeosasis 364 yperphaspratasia 364 iypophesphaasia 364 Collagen disorders eadingto inappropriate mineralization 365, ‘Osteogenesis imperfecta 365, Fbrogenesisimpefectoessium 366 FrodysplasaasMearspogressiva 367 Osteopekiesis 367 Osteopathia stata 367 ‘al-Potelesyniome 367 More's syndrome 367 omocysinuia 368 ‘Skeletal dysplasias dueto chromosomal aberrations 368 Tisomy a 368 Tisomys 368 Deletion sp 368 Tamers scome 369 iets syndrome 369 ‘Skeletal dysplasias due to congenital metabolic disorders 369, Mucopalysacchaséoses 369 Macolpiteses 370 Lipidstorage senses 370 PART THIRTEEN Neoplastic conditions 37: General princlples ofneoplasia 372 Definition 372 Characters ofbenign anc malignonttumors 374 Fancion ofreoplesticels 372 Epidemiology 372 Causes ofooptesie 372 Gancerinamiauty 373, Poleopattotgiasudyofneoplsms 374 Tumors of osseous originor differentiation 375 ‘Osteoma 375, Soltarenososs 375 ‘Osteotzorteome 376 ‘steobiastoma 376 Ossiying flvoma 377 COsteogentesarcomo 37 Tumors of catlage origin or differentiation 379 Ghonstome 379 Chondoblestoma 380 Chondiomyoid foroma 383 Osteochondroma 383 Chondosecome 38:Tumorsf fibrous connective tissue origin or differentiation 382 Desmoplsticflroma 382 Nonesiving roma 383 Fovesarcoma 383 Fibrous hstocyionaond malignant fbroushistoeyoma 383 Lipomalposarcoma, ond eiomyesocoma 383 ‘Tumors of vascular diferentiation 384 Hemangioma ofbone 384 Glomus tuner hemerpoperetoma, ond hemangoendothelioma 384 ‘nalosacome 384 ‘umors ofneurltisue 385 Neuslenmoma(Scheenrama)neuofbrome, ond newrofbrsecoma 385 Notochord tumors 385 (orfoma 385 Miscellaneous tumors of unknown origin 385, lant cel mperativegronlome 385, Meriogioma 385 Glantcaltmor 386 Eningssacoma 387 Primary malignant iymphoma of tone ~ 388 Metattc skeletal lesions 388, Boneests 390 Part FOURTEEN Diseases of the dentition 393 Oralbiology 393 Tatoduction "393 Developmentofdertion 394 Descriptive tomiology 394 Dentalannattion 395, [Embrology oooth development 395 Toothenption 396 Description oftoothtsues 396 Perodanti 396 Dentalaricustion 397 ‘tition 398, Physologialattion 398 Paleopetroiogyofattion 399 ‘Temporomandibularointdsease 399 Periodontal disorders 400 (assfeaton anddescription 400 Epidemiology ond anata features relevent periodontitis 40% Pathogenesis ofperiodonttis 403 “Antiquity istongand peleopthotgyofperiodontis 402 Dentalcaies 402 Defiton 402 ‘Epidemiology 503 Pathogenesis 403 contents | xi ‘Antiquity stongand poleopahology 404 Enamel hypoplasia 40s, Deftan 405 Descrition ofthe enamel hypepesialesion 405 Pathogenesis 406 Condltonsteading to enamel hypoplasia 407 ‘Antquityandpeleopatology "407 Miscellaneous denttion-elated conditions 407 Weopesms 407 Gstsofthejons 408 ‘oseomyelts 409 Pagerslzeose 109 seromegely 409 Osteogenesis imperecta 409 Teothmutiotion 430 Parr FIFTEEN, Miscellaneous conditions «3 Pagetsdiseaseofbone 433 Defntion epidemiology and etiology 433 Natwalistory 433 Sheetllesions 434 Complications 4x6 Paleopathotogy 436 Leontiasisossea 437 yperostosisrontalis interna 439 ‘Generalized hyperostosis with pachydermia(pachydermo- hryperostosis) 419 Paleopatholoay 419 Fbrous dysplasia of bone (bro-osseous dysplasia) 420 Defntion, etiology epidemiology and pathology 420 fone dstibuion flows dysplasia 420 Completions 42 xraskeealfeotres 42 Paopatblogy 423 ‘Skeletal neurofibvomatosis (von Reckinghausens disease) 421 Defntion, etiology andepidemslogy 42% Natura istoryand pathology 428 Paleontology 22 Maristines 422 ‘efintion etiology and epidemiology 422 Intepetetion ofHaisines 423 PolecpattologyefHarisine studies 423 References 425 Index 463Preface Human paleopathology can be defined a the study of disease in ancient populations by the examination of human remains. So defined, it has been practiced to some degree for sore than a century. dhe past its practioners have come to the field with quite diverse backgrounds, though physicans and anthropologists have been the principal investigators, ‘These two groups bring not only overlapping but also com- plementary skill to paleopathology: Physicians havea superb knowledge ofthe nature, transmission and epidemiology of disease (though not necessarily its expression in bone), while amthropologiss’ mastery of osteology and understanding of hhuman behavior atthe population level is unsurpassed, The field's complexity has been compounded farther by the involvement of historians, molecular biologist, physicists, geochemist and those from other disciplines during the past several decades as these workers have focused their technical skills on paleopathology specimens, supplementing the mor- phological database with nonanatomic, often quantitative, {information Veteran paleopathologists from exch group have demonstrated they can acquire many of the skills of the other, Dbut we hope that leadership in each of these disciplines inthe future will ead to joint training programs In this volume we have attempted to present the nature of disease expressions in skeletal and soft tissue In 2 manner that, co the extent possible, will meet the needs of the occa- sional consultant or the career investigator Authors ofa com: prehensive, current paleopathology text must directly address the chimeric composition of its readership. One ofthe major decisions we faced was the range of topics to be included, Recognizing that gross pathology remains the core of paleo~ pathology, we chose an anatomic approach to this question's Solution: we included almost every disease that produces in human tissues an anatomic pathological change large enough to be detected by the unaided eye, Principal among ‘our exceptions to this rule are a few (mostly infectious)conditions such as cholera that produce no gross lesions, but ‘owe their inclusion to thei epidemic nature and their often profound demographic impact on affected populations. Fur- ‘thermore because one cannot diagnose a disease of whose existence one is not aware, many modem diseases. are included even if no example has yet been reported in the paleopathology literature. The degree of emphasis, however, Js scaled to the probability of a given disease’ appearance during a paleopathological investigation. Another controversial issue involved the question of inclusion of gross anatomic changes in preserved nonskeletal tissues. An argument could be made that only a handful of ppaleopathologists dissect human mummies and they are not among those who examine skeletons. The first of these assumptions was true a decade ago but is, happily, eroding rapidly, and the second never was the rule. Furthermore, ‘many diseases affect both skeletal and nonskeletal tissues, and an understanding of such disease processes is incom- plete if the paleopathologist is unaware of the soft tissue alterations. For these reasons we have inchuded soft tissue lesions, some of which have already been reported in mum- mified human remains ‘The distinctive feature ofthis text, however, isthe incit- sion of disease aspects not normally elaborated in paleo- pathology textsThe basis of their presence in this volume is, our (controversial?) conviction that detailed knowledge of how lesions come to assume the form they present to the paleopathotogist will be enormously helpful in the recognt- tion of their cause, Memorization of a disease’ osteological features may well be a necessity for paleopathology students ‘but it will not, of itself, lead the reader into an appreciation of the variation in severity, morphology and frequency that ‘characterize paleopathology lesions, Morphological expres- sons of various diseases overlap generously and lists of fea- tures can be threateningly confusing unless the lesions’ development is understood clearly The Natural History’ sec- tions are employed to present the disease as a succession of tissue events that gradually cause and shape the final form of the lesions. In this section we have tried to make it possible for the reader to create a mental image of the evolving lesions so vivid that our final listing of features will seem almost redundant. Equally important will be the reader's ability to anticipate and recognize the many variations a given disease's lesions may assume — far greater than the usually extreme examples selected for illustrations in text- books (including ours). Since the importance of recounting the Tesion’s evolution will vary with its nature we have adjusted the length of this section accordingly, perhaps least in traumatic and congenital conditions and maximal in Infectious diseases. Itis also our feeling that an understanding of the state of our knowledge about the ‘Antiquity History and Epidem- ology’ of a disease will help maximize the integration of ‘identified pathological conditions with information about archaeological, anthropological, cultural and other aspects of a studied ancient population. Hence, we have introduced these sections, nota topics of exhaustive depth, but hopefully adequate for the stated purpose. Certainly the information in these as well asthe Natural History sections could be extracted from other, independent texts in other fields, but the latter are not necessarily written specifically for the paleopathologis's needs (e.g the heavy emphasis on laboratory diagnostic tests and on therapy in usual medical texts). In addition we hope their ready access by inclusion inthis text will result in more frequent perusal of such material by the user Finally, differences in readers’ familiarity with medical terminology needed to be addressed. We resisted the tempta- tion to minimize medical vocabulary, for so doing would imply that paleopathologists do not need to know it. ris true that we might maintain understanding of our text by elabo- rate efforts to avoid technical terms, but the simple truth is, that lack of a reasonable familiarity with common medical terms will deprive the paleopathologist of the continually changing body of medical literature relevant to diseases of interest. Most directors of graduate paleopathology pro: grams are cognizant of its importance and thelr students can ‘expect to receive appropriate medical terminology training, Similarly when specific enzymes, cell membrane chemical receptors or antigens significantly affect the presence or vir- ulence of a disease, thelr technical names and functions are cited and explained to enable understanding of the mecha- nisms For example, the unique geographic population pat- tem of gene frequencies of Duffy red blood cell antigens only becomes comprehensible when the role ofthese ant- gens in the vivax malarial life cycle is understood. It is Important 0 note that these very features are also being exploited in the evolving nonanatomic laboratory tech- niques for disease identification in human remains. ‘We hope our efforts to produce this volume will both aid diagnosis and enrich its users’ experiences in this captivating ‘eld of study: The extent of acceptance ofthis text by its poten tial users may be a measure of how appropriate our assump- tions are. We welcome readers’ suggestions for changes in subsequent editions. Amman C Aurore CConnano Roonicuez MaRSAcknowledgements In addition to the many dozens of individuals whose willing- ness to provide specimen photographs is acknowledged in the figure legends, we wish to call attention to several who helped usin unique ways. Mary Auferheide not only shared both the grime and the sublime of the many field trips whose results ace incorporated within chis text, but her linguistic talents and personal warmth overcame the many obstacles to such field exercises. Her unfailing faith in our ultimate success provided the support necessary to endure the natural, social and mali- tary crises that seem co be an inseparable feature of global fil perambulations. Hlena Garcia de Rodriguez-Martin supported the preparation of this book through her patience during the ‘many hours her husband devoted to searching bibliographic sources and writing chapters. She also made major contribu- tions tothe preparation of the manuscripts and the final selec- tion of the many specimens to be photographed. We also note the enormous contributions made by Sara Hammer of the Paleobiology Laboratory in the Department of Pathology atthe University of Minnesota, Duluth School of Medicine. Her ‘enthusiastic participation in and commitment to the produc- tion of this volume was clearly key to its success. Her incredi- ble ability to find and gain access to sixteenth century documents, compulsion for accuracy in bibliographic detail, editing text that invariably improved its quality, dogged pur- suit of permits for use of copyright-covered published lustra- ‘ions and indefatigable efforts to meet deadlines were essential elements in bringing this manuscript to publication, We thank rs Stanley Aschenbrenner and G. Rapp (archaeologists, Uni- versity of Minnesota, Duluth) for their innumerable consulta- tdons that provided both fact and perspective necessary for our proper understanding. Also to be acknowledged is our debt 10 those museum curators who made their collections available to us for photography, especially Paul Sledzik and Dr Marc Micozzi of the National Museum for Health and Medicine, Gretchen Worden of the Matter Museum, Bruce Latimer and lyman Jellema of the Cleveland Museum of Natural History,vel | ACKNOWLEDGEMENTS. Dr John Gregg and photographer Glenn Malchow in the Department of Archaeology athe University of South Dakota, De Jon Kramer of the Potomac Museum Group (the mam- moth metatarsal with osteomyelitis) and Rose Tyson of San Diego's Museum of Man who not only provided specimens for photography, but allowed us access to the electronic pale- copathology bibliography she was developing that proved to be of great value to us, We are also very grateful tothe staff atthe ‘Archaeological Maseum in the Univesity of Tarapac in Arica, Chile for granting the opportunity to carry out so many dis- sections of mummified human remains under Dr. Marvin Alli- son's supervision and sharing their experience with us. The Guanche mummy and skeletal collection at the Museo Arque- ol6gico de Tenerife, OAM.C-Cabildo de Tenerife (Canary Islands) was especially valuable, itwas made available o us by the generosity and enthusiastic support of its director Rafael Gonziles Antén and his helpful staf We are deeply indebred to Mrs Kenneth and Donal Brickson, Guilford and Rondl Lewis and other contributors to the Kenneth Frickson Memorial Fund for making it possible to acquire and properly process the hundreds of illustrations in this volume. Mercedes Martin, member of the Instituto Canario de Paleopatologia y Bioanthropologia (also belonging to the O.A.M.C.-Cabildo de “Tenerife) helped in che preparation of manuscripts and in the selection of specimen photographs. The many superb pho- tographs, as well as the skeletal paleopathology bibliography contributed by Dr Domingo Campillo (Barcelona, Spain) were extremely useful, We owe a special debt to Patrick Home for his contimaing interest and help in reviewing text (paleopara- sitology) and showering us with fascinating arcane articles and photos. The reviews of other chapters by Drs Keith Man- chester and S. Aaronson improved their quality enormously and deleted or modified multiple errors. Dr Bruce Ragsdale helped greatly with photographs of neoplasms as did Dr R Hay with cxamples of dental pathology Dr Conrado Rodriguez Maffote, reired professor of Orthopedics and History of Medicine inthe University of La Laguna (Tenerife, Canary Islanés) contributed many important ancient articles on skeletal pathology and history of medicine, as well as his suggestions on both matters. He was the person who into- duced me (CRM) to the wonderful world of human paleo- pathology when Iwas student in the School of Medicine of the University of La Laguna, Permission to reproduce illustra ‘dons ofan amelobastoma and that of a patient with advanced osteitis fibrosacystica by Dr Slootweg and DrAnne McNicol respectively, allowed valuable additions. Dr Saras Aturalia and “racy Kemp helped with critical deadline crises. The ongoing friendly and helpful photographic and art services of Mark Summers and Dan Schlies at the University of Minnesota, ‘Duluth were invaluable to us, as were the specialized services ofthe staff at Custom Photo in Duluth, We thank Antonio Yea, director ofthe Centro de Fotografia Isla deTenerife (AM.C- Cabildo de Tenerife) and his collaborators for thei efforts in preparing illustrations of the many specimens at the Museo Arqueologico de Tenerife. We also appreciate the help provided by the World Health Organization, It was Dr BT. Bell of the Department of Pathology at the University of Minnesota, Min- neapolis who generated in me (A.C.A.) the fascination of the field of human pathology, taught me its technology and nour- ished in me the spirit of scientific curiosity that ultimately led to my contributions co this volume. Finally, Dr 0. Langsjoen was the author of Chapter 14 and would like to make the following acknowledgements: 1 express my sincere gratitude to the Archaeological Research Center in the Department of Archaeology at the University of ‘Tarapara, Arica, Chile for providing access to their museum skeletal collection, A special thank you is also due to Mavis Langsjoen for organizing and recording the on-site data col- lection, Sara Hammer for innumerable secretarial services, the staff of the Educational Resources Department, University of ‘Mimnesoa, Duluth School of Medicine for figures and graph- fs, and Dr Arthur Aufderheide for his invaluable counsel and thoughtful review of the manuscript for my chapter. “Theoughout this 3-year effort, however, ic was the patience and continuous support of our marriage partners, Mary, lena and Mavis that made this production possible, Abbreviations for photograph sources in figure legends BM, [Briest Museum, Department of Pathology, University of Minnesota, Duluth School of Medicine, Duluth, MN. CMNH, Cleveland Museum of Natural History. DMNH, Denver Museum of Natural History Guanche, Aboriginal from Tenerife, Canary Islands, Spain, MAA, Museu Arqueologic d’Alcoi, Spain, , Instituto Canario de Paleopatalogia y Bioantropologia, MAC, Museu d’Arqueclogia de Catalunya, Barcelona, Spain. MAT, Museo de Arqueolégico deTenerife, Canary Islands, Spain (OAMC) MAUT, Museo Arqueologico, Universidad de Tarapaca, Arica, Chile, MM, _Miitter Museum, College of Physicians, Philadelphia, PA. "National Museum of Health and Medicine, Washington, DC. School of Dentistry, University of Minnesota, Minneapolis, MN, PBL, —_Paleobiology Laboratory, University of Minnesota, Duluth Schoo! of MedicineDuluth, MN. UB, Universitat de Barcelona, Spain,Part ONE History of paleopathology INTRODUCTION “The evolution ofa scientific discipline is usually portrayed asa chronologieal succession of rime segments, each of which is characterized by shared concepts, methods or othe features ‘The few, extant reviews of paleopathology’s history by such writers as Jarcho (1966e) in the United States, Swoppiana (1973) in lay and Jaén (1977) in Mexico have all used a similar format, Although there are slight differences in the parameters of the defined ers, they all identified avery early period (prior to mid-nineteenth century) in which observa- tions of disease in fossilized animal bones were recorded. This ‘was followed by a second interval roughly contemporaneous ‘with the initiation and efflorescence of microbiology in the later half of that same eentury, during which the focus was directed at pathological changes in human skeletons. The third period, occupying several decades ofthe early rwentleth ‘century recorded considerable expansion of such reports and ‘included some classification efforts. Finally, the most recent era, beginning about mid-nineteenth century, demonstrates the maturation of this eld as reflected by an enormous {increase in publications with more exacting definitions, crite- ‘a, systematization and an explosion of new methodology. In this eview we will follow a similar approach as outlined by Rodrfguez-Martin (1989,1990) as well as Rodriguez Martin & Caseriego Ramirez (1991), who identified the following phases ‘Antecedent phase (Renaissance to mid-nineteenth century) Genesis of Paleopathology (mid-nineteenth century to ‘World War 1) Interbellum Consolidation phase (1913-1945) [New Paleopathology phase (1946 to present) “The features characteristic ofeach of these periods are detailed {nthe remainder of this compendium.2 | HISTORY OF PALEOPATHOLOGY ANTECEDENT PHASE (RENAISSANCE TO MID- NINETEENTH CENTURY) During this long period most work vas devoted to the study of diseases prehistoric animals. In Europe the first reference to ancient pathology was made by the Swiss anatomist Felix Platter (1536-1614) who, in his work De Coors Humani Structure et Use incor. reedy attributed several fossil elephant bones to human gigantism. The natu- alist Scheuchzer (1726) confused fossilized giant salamander bones (in 1726), identifying them as a buman victim of the ‘universal inundation’ ‘The German naturalist Johann Friede- rich Esper (1774) (Fig. 1.1) correctly diagnosed an osteosarcoma in a cave Dears femur, a feat hailed by Ubelaker (1982) as che birth of paleopathology A Quaternary hyena's occipital skull fracture was described by George ‘Augustus Goldfuss (1810) at che Uni- versity of Bonn, and lesions from other Quaternary animals were pub- lished by the Belgian, BC. Schmerling (1835), who also noted differential diagnosis difficulties. Though seudying primarily diseases of bears and lions, the importance of knowing the antiq- ulty of human diseases was empha- sized by Phillip Franz von Walther (1781-1849) near the end of this period (Walther, 1825), adding that inheritance may be a major fictor in disease origins. In America, Jarcho (19660) attib- luted the frst paleopathology report to the Boston surgeon John Collins ‘Warren (who also performed the frst ‘operation on an anesthetized patient) for his description of American abo- riginal deformed skulls in his book A CCompartiveView ofthe Srl and Nereus System in Mon and Animals in 1822. Both fractures and anthropogenic deforma tion were described in 1839 by Sam- uuel George Morton in Crenia Americana Fe 4.1. Femar fracture and callus fossil eave Bean Fidich sper.) Frotslace (pot and () Pate 0 igure fam is 774 book ge bibliosaphy). Courtesy of Wangensten Historical Library Bolgy and Med ine, Unversity of Manes, Mineapots, NN CHANIA AMERICANA; ig. 1.2) Fie 1.2Cranlal daformation.Pehictorc native of seat vies, Chile Fam Conia Americana by Same George Mar ‘The end of this period was also mar- jon (8) Courtesy of Wangensteen Histol nary oF Bology and Medicine University of Mianesot, ked by the application of the micro- minneapals, WWFie, 1.3. Ovarian ey. From an Egyptian mummy isecod by August oz Granvile Reproduced rom Grav (eas Pilasophica Tensction of he Roel Society London. Fi. 1.4 Rudo Vichot Pathologist, anthropologist, statesman who applied the prints ofhis tule on cla pathologyfoancerthuman femains. Reproduced ram Naodle (39234). gure 7, 9.84. permission University of chicago Pes, chicago IL. GENESIS OF PaLEOPATHOLOGY | 3 scope to sue structure. The Swiss (Neuchatel) professor Louis Agassiz studied fossilized dental microstruc- ture between 1833-1843 as did the British anatomist Richard Owen (1804-1892), and the British gynecal- fogist and pathologist Augustus Bozzi Granville (1783-1871) reported his- tological observations of samples from a cwenty-seventh dynasty Egyptian murnmy he dissected (Fig, 1.3), In summary, this period's reports ‘were isolated observations of a des- criptive nature cartied out mostly with litle scientific precision and on spect= ‘mens viewed primarily as curiosities, not as sources of medical pathological or historical knowledge, Thus they are ‘most appropriately viewed as ante- cedents to the scientific discipline of paleopathology. GENESIS OF PALEOPATHOLOGY (ip-NINETEENTH CENTURY TO WoRLD War I) While a number of pioneering physicians and anthro- pologists clarified the medical nature of ancient skeletal pathological changes during this period, primary interest in studies of human remains remained anthropologically- focused, Archaeology can be said to have initiated in north- cen France when Jacques Boucher de Crevecouer de Perthes (1788-1868) found, in 1847, stone tools associated with animal bones in a canal. Subsequently the steady stream of excavated human and animal bones generated large osteo- logical collections at museums and universities. Study of these skeletal tissues was carried out principally out of inter- est in their value to physical anthropology (then focused largely on racial origins). However, the incidentally observed pathological lesfons in these bones did attract a number of physicians and anthropologists who were curious about the nature of the diseases that may have caused them. Their diagnostic evaluations were enhanced with application of ‘Wilhelm Konrad Rantgen’s discovery of X-rays thatled to his Nobel award in 1901. While the number of publications pro. liferated dramatically, most were characterized by reports of| individual, offen spectacular cases. Few of the authors appre- ciated the value of those diseases’ paleoepidemiology. ‘Among these was the German physician, pathologist and statesman Rudolph Virchow (1821-1902) (Fig. 1.4). In 1856 he examined a human skull from a Feldhofen cave (Neanderthal Man) and declared it pathological, In subse quent years he published other papers dealing with lesions4 | mistoRY oF PateoPaTHoLOsY ie 15.Janos Cermak, Cech meical cenit who peter stooge studies on mummy tsues Reproduced fom Ceemal (879) Courtesy of \Wangensteen Historia Uber oF ology and Mal, Universty of in reso, Mineapal, in paleolthic and Neolithic human and animal remains (Virchow, 1895), suggesting that disease isa form of altered life and therefore is probebly as old as life itself! However, Virchow’s interest in these lesions remained largely medical He had no manifest interest in the epidemiological impact of disease on culture, a view considered by most as too limited to eam him the designation of the'Father of Paleopathology’ Im addition to Virchows, others who made earlier, occasional contributions include J. N. Czermak (1879) (Fig. 1.5) (A CCasch, who used histology to identify arteriosclerosis in an Egyptian mummy 50 years before Ruffer did [Steouhal & \Vyhnének, 1979]), Kovacs (1843, tepanation in Hungary), KW Mayer (who studied the zoopathology of the Quater~ sary animals) and LA. Gosse (1861). Twas, however, the French investigators who le the pale- pathology procession in the later half ofthe nineteenth cen- tury-The Parisian surgeon and medical school professor Perre Paul Broca (1824-1880) startled workers in this field when he auwibuted a Peruvian skull defect to antemortem surgery in 1867. He ako published on congenital parietal defects im 1875, His other achievements induded the study of Cro- Magnon man and establishment of the Société’ Anthropolo- sein 1859, the Revue d’ Anthropologie in 1872 and the cole a’ Anthropologie in 1876, His contemporary, M. Pruniéres (1874) separated the postmortem tepanations and rondelles from antemortem operations, and also described tuberculous lesions in Neolithic bones. By 1878 Just Mare Marcelin Lucas- CChampionniéze (1833-1913) was able to waite an entire ‘book, ta Tigao, on that wpe, asserting the operation was performed for boca magical and therapeutic reasons, and not- Fie. 1.6 Cranial epanation. Sle remains oF aboriginal (Guanes) rom Tener, Canary lelands Repraduced fom Felon Lschan (8962, figures Aan nso Canaria de Paeopatloiayntropolgl ing that the ancient surgeons prevented lethal hemorshage from the sagital sinus by avoiding the sagival suture, Leonce Manouvrler (1904) had also described the neolithic sincipital ‘Type of cranial cauterization in 1895. Campillo (1983), however, feels thatthe general reatise sions Oss de Homme Prhisorigue ex Fre em Algiri, written by Jules Le Baron in 1881, was milestone both for the French workers and for the scientific field because it was a general treatise on paleopatho- logical lesions gleaned from the thousands of bones collected athe Museé Broca and the Museé of Paris, and in which diag- nosis and predicted etiology was attempted. Among ether European workers during this period, Felbe von Luschan (Berlin) described trepanation and cauterization 4m the Canary Islands’ aboriginal (‘Guanche’) skulls during the last years of the nineteenth century (Fig. 1.6). Similar ‘observations were made and classified on Guanche remains ‘curated in the university museum's Institute and Humanities School at La Plata, Argentina by Robert Lehmann-Nitsche (1904;Rodriguez-Martin, 1990), while yet another German, etloff von Behr, published a monograph in 1908 on dental, pathology of the Guanches. In addition, further reports were ‘contributed by Djordje Jovinovic and Dragutin Gorjanovic- Kramberger in Yugoslavia, C, Engelhardt, §. Hansen (1894: 242-69), H. Kjaer and HLA. Nielson in Denmark as well as ‘Gregorio Chil y Naranjo (1878) in Spain who was the fist co identify Guanche trepanations. Im the United States the forensic specialist Joseph Jones (1833-1896) excavated and reported treponemal lesions from bones in Kentucky and Tennessee, also studied histo- Togically At Harvard University the work of three physicians had enormous impact on physical anthropology and related areas (Jarcho, 1966). Jeffries Wyman (1814-1874), curator of Harvard's Peabody Museum in 1871 described periosteal inflammation that Jarcho thinks may have been syphilis. In 1878 Frederick W. Pumam (1839-1915) debated the possi-bility of syphilis described by Joseph Jones. The curator of the Warren Anatomical Museum, William F Whitney (1850-1921), published the first American paleopathology ‘manual Nots onthe Anomalies, Injures and Disests ofthe Bones ofthe [Native Ras of North America, in 1886, Finally, Joseph Leldy (1823-1891), pathology professor from Philadelphia, pathologist and archaeologist Tophil Mitchell Prudden (1849-1924) as well as pathologist and archaeologist Josiah Clark Nott (1804-1873) made periodic reports of lesions, swhile cranial wepanation was studied in Peru by Otis T. ‘Mason (1885), in Bolivia by AJ. Bandeller (1904) and in ‘America by P. McGee (1894, 1897). Most of these reports, however, lack useful detall. David Matto (1886) and Antonio Lorena (1890) were contemporaneous South American sci- ‘entists who reported trepanation among the Incas. In addition to human investigators, the period is also dis- tinguished by the formation of three institutions whose ‘oxteological collections contributed to paleopathological INTERBELLUM CONSOLIDATION PHASE | 5 studies. The US. Army Medical Museum (now called the National Museurn of Health and Medicine) was created in 1862 to house legs amputated or other abnormal tissues extirpated on battle felds of the US. Civil War in the hope that their study could reduce surgical mortality. Between 1898 and 1904 it donated 3500 skeletal specimens to the "National Museum of Natural History (a part of the Smith- sonian Institution), Keeping only the pathological speci- mens. In Europe the Museé de L’Homme at Paris began and continues to enlarge one of the most important osteclogical collections in the world, though its primary interest was normal morphology and osteometrics INTERBELLUM CONSOLIDATION PHASE (WorLD War | AND MARC ARMAND RUFFER TO Worto War I!) Jt was during this interval that paleopathology expanded, systematically applied the methods of radiology, histology serology, and others, and also introduced statistics into such studies. The resulting improvements in diagnosis and the concept of linking disease to culture led to the evolution of paleopathology asa scientific discipline. The wave of Egyptomania, inidated by Bonaparte’sinva- sion of that country and fanned by Champollion’s decipher ‘ment ofthe Rosetta stone, led to the extensive excavations that produced a large number of mummies available for seudy early in the twentleth century. The British anatomist Grafton Eliot Smith & Warren Dawson (1924) (Fig 1.7) and the chemist Alfred Lucas (1926) made major contributions to paleopathology by examining grossly dhese mummies and chemically analyzing naton and other substances in thelr tissues. But it was Marc Armand Ruffer (1859-1917) who Jed the way with the detailed documentation of his innova tions and observations. Born in Lyon into an aristocratic fam- ly of a French baron and German mother, he acquired sedical traning in Germany and bacteriological expertise at the Pasteur Institute (Garison, 1917). There he contracted diphtheria and went to Bgypt in 1891 for convalescence While a professor at che English Government School for medicine n Cairo, head of the Red Cross and president of the Sanitary, Maritime and Quarantine Council of Egypt until 1917, he recognized the wealth of potential meal knowl- eee that could be extracted by examination of the accumu lating excavated mummies, Afer 1908 an uninterrupted flow of his publications about the idendfeation of schisto some or, atherosclerosis, osteoarthris, congenital coudi- tions, malaria, wberculosis and other diseases reflected the application of his medical knowledge and techniques to ‘mommy dssues with awareness of their epidemiological inaplications (Sandison, 19672). He developed a method of rehydrating mummy soft tissues and preparing histological 57. Osea mri ith at Eeian mun Tissue in Sith Oso’ 2) tok son armies, Smits egress assem ‘atrpernisin ot egan Putten! Londen and New Yr who reprinted the cringe beking5.6 | nistoRY oF pateoparHowosy slides that expanded substantially the range of dlagnosabl diseases. It wat he that popularized the term ‘paleo- pathology designation tat had been Suggested. earlier by the physician RAE Shuféldt (1892-93) and that had appeared in Fnkand Weal! Sted Diciemty since 1895 (tcho, 196 ‘blr, 1982). 121917, while retro ing fom a public sanluadon projet in Greece, he died tagialy when the warship on which he was 3 passenger vas torpedoed by 2 German submarine ‘An anthology of his aries (Bg. 1.8), collected and edited by the paleonol- gist Roy Lee Moodie, was published tn 1921 under the te Ss inthe Phy of Hype Oday, after this brian begleaing the sy of mum mes itered fe is dest, and paleo ptologiss returned to this ners in Sele pathology Other French contributions dusing this period included the use of Xras fon anent human remains in 1923 by M Brudouin, a procedure that enabled him to study theumatic dense, hip dlsocations, dental paleopuology and cher conditions (Sroppiana, 1973). The mltar surgeon Ten Paes n1930 published his teatse Puiplle « Pidolge Compete, desing wit aif time of stuly of a broad range of Giseases and in which he noted rela tonships between disease, eveluson andspecies extinction A valbl listing (of 660 paleopathology references was {nduded inthe book. Emile Guard also published a book in 1930, Lenin re cr tus et hs oi tis Maden, in 1930 dealing wilh the relationship of cranial wepamation to brachiocephaly. Neolihic cranial epanation and ronmetic spine traits were aio the focus ef pibllcaions by Forgas MB Barbosa Scio Further Portgiese reports on paleopathologica obser: tian were contbuted by the anatomist Hemant Montero and the medical historian Lulz de Poa (1968). In Denmark, EM. Christopherson ste palecstomatology in the decades ofthe 1930s and 1940s, and K- Inger published a monograph tcusvely devoted to diseases and injuries in ancient skeletal Temains (Bennike, 1985) kor Tall (Hungary), J. Pevoric (fugonva) Domini Waifl (Germany: ancien epanation STUDIES IN THE OF EGYPT ‘oases oY 1, MOODIE, Pap. Fis 1.8 Sir Mare Armand Rule. From Ruts collected papers published n gz as booked his endand ‘colleague Roy Moodie With permission or the Univesity of Chleago Press Chicas, I, DISEASE Fie 1.9, Hemangioma in bone of dinosaurtal Fonspece in Roy Moodie’ (15232 The Antiguity of Disease. ith permission fom the Unverslty of ncag Pes, hago IL and cauterization), and Juan Bosch Millares (1975: Spain — Canary Islands) were numbered among other contributing European paleopathologists In the United States the same Roy Lee Moodie (Fig 1.9) ‘who edited Ruffer’s anthology also published a massive tome ‘in 1923 entitled Paeopathology- Aa Ineduetion tothe Sty of Ancient Evidnes of Diswse (Moodie, 1923). Trained in anatomy and PALAEOPATHOLOGY ANTIQUITY OF‘THE NEW PALEOPATHOLOGY | 7 ing chronological changes in disease frequency (Ormer & Patschar, 1985). He fleld-tested chese methods in his early studies inthe Canary Islands (The Ancient Inubltuns ofthe Canary |alnds, Hooton, 1925) and then applied them in a major way to his epochal work in the southwestern United States of America, published in his now famous The Inians of Pas ucla: Stuy of Thlr Skeletal Remsins (Hooton, 1930). He also. recommended the creation of a collection of modern osteo- logical lesions of known etiology to serve for comparative paleopathology research, Other American paleopathologists included Herbert U. Williams (1866-1938) who published a general review of paleopathology (1929), Weber (1927), Michaelis (1930) and Netman, These investigators used radiology and histol- ‘ogy to diagnose syphilis and other Iesions during the 1920s and 1930s. George Grant MacCurdy’s (1923) study of Jhuman skeletal tissue from Peru's Urubamba valley is a splendid example of meticulous application of ostealogical ‘methodology. In South America, Zambaco-Paché published a paleoepi- demiological study about the antiquity of syphilis in 1897 Fi, 1.20,Ales Mrdlcka He developed the Pyscl Anthropology Section ofthe Siithzarionnsttuton, Megat HN 3, 533, National Anthropological ces, the Sitgonan Instn, Washington DC focused on paleontology, Moodie devoted about one-third ofF his book to Iesions in human remains, analyzed previously published reports and used about two-thirds of his volume to document disease in ancient plants and animals, many of which had been fossilized. Combining microscopy and pho- tomicroscopy he documented the antiquity of disease in fos- sil plans from the eazly Paleozoic period and demonstrated bacteria in Carboniferous Age foslized remains. In 1931 he again recorded the results of another major study ~ radio- Jogical study ofthe lage collection of Egyptian and Peruvian ‘mummies atch Field Museum in Chicago These two publi cations provided a major impetus to the developing Meld of paleopathology North American paleopathology experienced another zmajor impact with the appointment of the Czechoslovakian- bom Ales Hedlicka (Fig 1.10) tthe anthropology staff of the National Moseum of Natural History at the Smithsonian Insti- tution in Washington, DC, where he created the Division of Physical Anthropology Though his field methods may not always have resulted in random sampling, he developed large oxteological collections from both North and South America that are sll the objects of study today. Nevertheless, his pri- rary focus remained physical anthropology (Hrdicka, 193%; Ubelaker, 1982). Many of his publications concern cranial fea tures including trepanation, ear exosto lence, summarized in his mjor opus Anthropol Wo in Paw in 1913 with Notes the atlogy of he Acer Rerwins (Hedlicka, 1914) He also denied the pre-Columbian presence of tuber- calosis in Ameria irdlicka’s contemporary Harvard's Famest Albert Hooton introduced a demographic perspective, using a statistical, ecological and cultural approach to physical anthropology (archo, 19666; Rodeiguez-Martin, 1989b), also demonstat- snd lesions of vio and a similar approach was used in his study of leprosy in 1914, More well-known is the archaeologist Julio C. Talo (1880-1947), professor at Lima's Universidad Mayor de San Marcos and director of the National Museum of Anthropol- ogy. He studied artificial mummification of the head, trepa~ nation and medieal practices in Peru, and published a book (1909) on the antiquity of syphilis, alleging its pre- Columbian existence in that country. ‘Thus it is evident that the sporadic, hesitant and isolated paleopathological observations of the previous period were consolidated during the period between World War I and Il with the introduction and gradual standardization both of ‘new methods and new interpretive concepts, resulting in the ‘emergence of paleopathology as 2 scientific discipline. THE NEW PALEOPATHOLOGY (Worip War II UP TO THE PRESENT) ‘A major chapter of paleopathology ended with the first fires of World War Il. After this conflict, paleopathology was ‘viewed in a diferent way: as an important cool for the under- standing of past populations. It was during this stage of our iscipline that paleopathology was related to epidemiology and demography, and when the new techniques coming from clinical and laboratory medicine allowed a much more secure diagnosis, Angel (1981) divides this new activity in paleopathology into four different areas: 1. Patterns of traits necessary to limit diggnoss. 2. Social biology othe relations between health status and society 3, Demography and health.8 | HisroRY oF PaLEOPATHOLOGY 4, Growth, related mainly to nutrition, including bone chemistry Recently the facinating field of genetic research has been Introduced to paleopathology Ie is now possible to diagnose infectious diseases, such as tuberculosis and possibly we- pponematoss,chrough the extaction of ancient DNA of the bacillt from mummified tssue or archaeological bone, and its amplification by means of the polymerase chain reaction (PCR: Spigelman & Lemma, 1993; Salo etc, 1994; Rogan & Lentz, 1995) But the great impetus of paleopathology emerged during the later part ofthe 1960s and especially during the decade of the 1970s. Most authors agree that the common use of modern diagnostic techniques was responsible for the scien- tie character ofthe discipline (along wih the improvement of the new approaches that had appeared before World War It) that permited the study of complete populations and not of isolated cases only: Thereafter, paleopathology ceased to be merely a curious complement tothe history of disease, and became an ambitious branch of science: historical pathology endowed with true sientifc rigor. Buikstra & Cook (1980) stated that the most important advances in paleopathology are included in the following 1. Major synthesis of information 2. Disease diagnosis and paleoepidemiology. 5. Nonspecific indicators of stress +. Paleonutrition 5. Investigation of mummies and mummified tissues. 6. Inerdisciplinary work among the researchers interested ‘ paleopathology However, as Ormer & Auflerheide (19918) point out, it seems tht inad- quate attention has been given to theory in our discipline, and "perhaps the most urgent need in paleopathol- ogy is careful review ofthe methods wwe are using’ This fact appears larly in different issues: meaning of disease for the individual and populations, and not only description of lesions; evolution of disease; derstanding of “what constitutes disease versus what constitutes 2 dysfunctional biomed- jaal esponse:’ relationships between population density and disease; and, finaly, the impact of the cultural and social changes on human health and disease evaluation, Ortner (1991) suggests progress of the discipline requires develop- ment of other, related scientific feds Oriner divides the future develop- ment of paleopathology into six dif ferent stages: 1, Definition of the specific area of scientific interest. 2. Once this area is defined, the creation ofthe methodol- ‘ogy to investigate ic becomes necessary 3. Creation of abody of descriptive dara related to the subject’ 4. Development ofa classification system, Generation of hypotheses regarding the significance of observed phenomena, 6. Relating data and hypotheses to similar research and the- ory in cognate fields. In addition to those new and important theoretical approaches, itis necessary to call attention to one of the most important events in the present development of paleopathol ‘ogy: the creation (in the 1970s) of the Paleopathology Asso- lation in Detroit (Michigan) by Aidan and Eve Cockburn (Fig. 1.11) as well as other scientists. The predecessor to the Association was the so-called Paleopathology Club, formed in 1973 by a group of Canadian and US, scientists, along ‘with a visitor from Czechoslovakia, chat met in Detroit for a symposium sponsored by the Smithsonian Institute, the Detroit Institute of Arts, and Wayne State University Medical School, and which completed a multidisciplinary autopsy on. an Egyptian mummy (PUM I: Cockburn, 1994). Currently, the Paleopathology Association is an informal group of more than $00 researchers worldwide coming from different dis- ciplines and interested in ancient diseases, and, as Cockburn (1994) states, the organization still observes the original statement of purpose: It has neither funds, rules, nor of8- cials, bu exists solely to provide channels of communication among workers who are active in the field: This association hholds an annual meeting in North America (US.A. and Fo. .11, Aidan and Ee Cockburn. Founders ofthe aleopthology Associaton ns973,andploneers of nes say approchto mummy dissections. With permission rom Eve Cockbum. PBLTHE NEW PALEOPATHOLOGY | 9 researchers coming from such differ cent specialties as archaeology and genetics, history and paleopathology, diet and chemistry, and others. Col- Inboration beeen researchers of aif ferent disciplines is becoming more the rule than the exception. Only in this way ss it possible to understand fally the way of fe and death of past populations. Led by the example of PUM It and subsequent studies dur- ing the past decades, several such pro- jects have emerged that can serve as rodels of imterdisciplinary studies. IF ‘we consider only a few that included substantial budgets, large number oF researchers, and had widespread {nteraational impact, we can point 0 the Maebster Museum Mummy Projet developed during the 1970s on the Egyptian mummies curated in that ‘museum under the direcion of A F142, Marvin lion and Enrique Gersten. Founders fthePalcopsthology Cub in 978, an pioneers of ite ‘tin biomedca, boantrepologia and arehaelogcalnangsinassections ofPervanandChileen mummy populations. ih permission from Drs Alsan and Gerster. PBL. (Canada) and a biennial one in Europe. The first annual meet- {ng was held in Amherst (MA) in 1974, and the first Euro- pean one in London, 2 years later. Coupled to these events in 1973 the first issue of the Pulopthlogy Nemsleter, a quarterly publication, appeared as a means of communication among ‘workers in the eld, 4s Campillo (1993) recalls, Allison and Gerscten (Fig 1.12) created a Paleopathology Club in 1978 chat is affliated, with the International Academy of Pathology ~ United States and Canadian Division, serving as a means of exchanging information about specific cases and research problems, This Club also organizes an annual companion meeting of the International Academy of Pathology. According to Buikstra & Cook (1980), the Paleopathology Club has excellent poten- tial for ‘raising awareness among medical scientists concern- ing the nature and importance of research in paleopathology’ ‘More recently after the First World Congress on Mummy ‘Studies that was held in Tenerife (Canary Islands, Spain) in. 1992 (with the attendance of mare than 350 scientists com- ing from all continents) the World Committee on Mummy ‘Studies was created. Ths isan informal group of researchers, {interested in the fascinating world of mummies that is orga- nizing this specialized ficld of research in which paleo- pathology is one of the most important aspects. The Second ‘World Congress was held in Cartagena de Indias (Colombia) 3 years later with excellent attendance and presented improved techniques and research methodologies. Besides the creation of specialized associations and the annual, biennial or triennial congresses, the tremendous improvement of new research techniques has permitted the development of important interdisciplinary projects with Rosalie David (David, 1979). The ‘CRONOS Projet, the Biuthrpsogy of ‘Guanche Munmis, evolved between 1988 and 1992, targeted fon the Guanche mummies and skeletal remains of the Museo Arqueolégico de Tenerife, Canary Islands. Researchers from ‘many different disciplines, and from different countries took part (Gonaile2 Antén etd, 1990; Auféerheide, 1995). The British study of the bog body Lindow Man and the Danish project on The Greenland Murnmies are additional excellent examples (Stead ea, 1986; Hart Hanson etal, 1991). Hap- pily, many smaller investigations are becoming increasingly popular. ll ofthis interest has spawned many texts on pale~ ‘pathology during the last 30 years. A few of them are by single authors, others are coauthored, and still others are edited. Those most widely used, listed in chronological ‘order, include Bones, Boies, and Diese (C. Wells, 1964); Human Fuleopatology (edited by S. Jarcho, 19666); Diseass in Anigity (edited by DR. Brothwell & AT. Sandison, 1967); Pueopatho- loi Digs end Inerrtation (RT. Steinbock, 1976); ice tin of Plenptbolgis! Cantons in Human Stltal Renais (DJ. Ormer & WG), Putschar, 1981); Atlas of Humen Poepatology (MCR. Zimmerman & M.A. Kelley, 1982); The Arcbclogy of Dis- case (K. Manchester, 19834); Disease in Ancient Man (edited by GD. Hart, 1983); Faleopthogy ot the Origins of Agrcalture (edited bby MIN. Cohen & G}. Armelagos, 1984a); Human Palepatolgy (edited by DJ. Ormer & A.C. Aufierheide, 19914); Rae athlogie du Squelete Huneine(. Dastugue & ¥. Gervais, 1992); and Ppaaloga (D. Campillo, 1994-95). Many excellent productions with a more restricted focus or issued in less ‘widely employed languages are also available. ‘AsKerley (1976) points out, until 1975 a large fraction of the American physical anthropologist that regularly invest gate ancient diseases were engaged in teaching some form of10 | HISTORY oF paLeoParHaLocy paleopathology but with varying degrees of emphasis, with, different methodology, and to students of different levels. (One of the most important events in the increasing incerest {in paleopathology during the last decades is its academe development with the organization of courses of different levels of depth. One institution that could be considered as 2 ploneer in this field is the Smithsonian Institution with its ‘Paleopathology Program; under the direction of Dr DJ. COrmner, Although this program is not acedemic snsu strict, and its two major objectives are research and the develop- ment of a registry of skelecal diseases (Ortner, 1976), it was an example for the development of other courses and pro- grams in the US.A. and other countries. ‘The example of academic organization in the fed of paleo pathology that many other institutions use as a model isthe Calvin Wells Laboratory for Burial Archaeology nove located at the University of Bradford (UK.) which has inchuded the discipline asa research ané teaching activity ince 1978, (Other institutions in different countries generate regular courses on the subject. One of the most well-known is that ‘organized periodically by the Museum of Health and Medi- cine at the Armed Forces Institute of Pathology at Washing ton, DC. In other countries (Brazil, Spain, France, Italy, Geranany, ete) other interesting courses on different aspects of this branch of science are organized with great academic and scientific success. poPart Two Pseudopathology INTRODUCTION One of the most vexing problems a paleopathologis faces is the question of whether a given tissue change is an ante- mortem pathological lesion or a postmortem artifact. A pseudopathological feature isa structural change in normal bone oF soft tissue that resembles the lesion of some ante- ‘mortem disease but is, in fact, purely the product of a post- mortem process. Occasionally a normal structure will have the dimensions or appearance that is sufficiently near one end of the spectrum of the normal range to be mistaken fora disease process, Experience, of course, will enhance the cer- tainty ofthe answer to that question. Some postmortem fea~ tures, however, are so common that awareness of these conditions will help obviate inappropriate interpretations. It is the purpose of this section to call attention to the most prevalent of circumstances leading 0 pseudopathological alterations of normal tissue Certain general principles operate to produce the appear ance of excavated human remains. The different parts of bones or soft issues vary in density, shape and size, causing ‘differences in the extent to which these areas resist environ ‘mental influence such as acid groundwater or mlerobiologi- ‘al agents. Furthermore, antemortem lesions often render the affected tissue more susceptible to postmortem effects that may obscure or mask them (Henderson, 1987; Ortner & Putschar, 1985:44). In such examples differentiation of ante- mortem and postmortem effects at the same location may be a formidable and even sometimes impossible challenge In addition to the above, Ormer (1992) has identified sev- eral considerations he finds useful in differentiating pathol- ogy ftom pseudopathology. They include: 1 Integration of anatomical radiological and microscopical data.2. Notation of the type and the distribution pattern of the changes under consideration. 3. One's realistic expectations should include the admission thar resolution of such questions is not invariably possible. Waldron (19878) has also called attention to the fact that 3 generally poor level of skeletal tissue preservation will result {in loss of many antemortem lesions, inviting an erroneously low estimate of such a population's disease frequency. ‘The following pages note common changes in human tissues that frequently lead to inappropriate pathological diagnoses secondary to the environmental agencies of mechanical forces, chemical and microbiological agents, {mmprints by botanical or animal agents, excavation and labo: ratory handling methods as well a radiological artifice, SOFT TISSUE PSEUDOPATHOLOGY Soft tissue pseudopathology can be defined as an anatomic postmortem change in soft tissues that resembles an ance ‘mortem pathological lesion. Causes can include the follow- ing mechanisms. bod Reveals unwrapped contents: skeetonized heb spine and peli, Pseudopathological features related to mortuary practices Substitution of body parts Egyptian embalmers sometimes included an additional leg, head (Notman, 1986) or other body parts. Occasionally they ‘employed parts from multiple, different bodies, wrapped (0 resemble single, intact adult body externally (Aufderhelde et a, 1995; Fig. 2.1). Degenerated external genitalia frequently were replaced with models using resin-saturated linen cloth, ‘Northern Chile's ancient Chinchorro peaple often fita wig of adult human hair on their mummified infants. Adolescent males of the Ecuadorian Jivaro (Shuar) natives learned the technique of shrinking human heads by practicing on sloths, producing heads with a deceptively human appearance that hhave appeared in the art market (Fig. 2.2). Bven the label on reliquaries cannot be crusted to guarantee the modem con- tents of those receptacles (Zimmerman, 19938). ‘Subdermal masses Excessively tightened ropes encircling the body to Ax ‘mummy wrappings into position can cause the skin and ‘iaht eg andleleghad been obtained rom four diferent indlduls, £2, Ts. olemalc Egyplian period Dakhleh oasis site. PB.SoFT TSsuE PSEUDOPATHOLOGY | 13, subcutaneous tissue to bulge above the level ofthe cords. Postexcavation unwrap. ping can cause these now-desiccated, bulging masses to resemble subcutaneous tumors, Closing body orifices ‘Vegetal tampons sealed the vaginal orifice of several adult Chinchorro females from northern Chile (Aufderheide & Allison, 1994). Orifice plugs were common mor- tuary features (ritual?) among this group's bodies, so it seems inappropriate to com: clude that such crude tampons were used commonly during menstruation by these ‘women, Similarly, the presence of oral coca leaf quids in mummified Andean bodies demonstrated no correlation with the presence of chemically identified cocaine in hair (Cartmell etal, 1991), sug- Fie.22, Shrunken head ho 9 Ecuadorian Faro (Sat natiessrankand mummifedhumanheadsofwar victims (2). Similiar howier monkeys’ heads (aor slothsin art market may have been prepared bytribalyouths gesting the coca leaves did not necessarily ‘seaming octual experience Photograph courtesy of David Muntand Raber Mann, NaionalMuscumof reflect antemortern leaf exposure by the Natural Histon Sitsonian nstason specific deceased individual, but more Fe. 2:3, coca tet quid nora cavity Half ofthis Tvanalcvelate population sion: cnca qld ngrave des not predic antemortem chewing epesens ff: ‘chewed coca leaves attests poste, utths bodyshairwas negative, Conc Ing). CHA 27. Ad female, PL14 | PseuooPaTHoLocy likely were comb offerings placed there by those burying the deceased (Auftlerheide etal, 1991: Fig. 2.3) Heat effects Heat ‘cooks’ the extremity musculature. The resulting muscle contracture flexes the upper extremities into a pugilistie pos- ture, a postmortem mechanism that is often betrayed by the broken, dry skin where it is stretched over the elbow (Knight, 1991:35), Embalming artifact Alkaptonuria (ochronosis) is a rare, heritable enzyme defl- ciency that deposits a black, insoluble substance on the carti- lage and collagen of intervertebral discs rendering them radiopaque (Rosenberg, 1991). Itis discussed in detal in ‘Chapter 9, but is mentioned here briefly because t was con- fused with an embalming artifact. When Egyptian rmam- mies’ radiographs frequently demonstrated radiopaque imervertebral spaces, the diagnosis of alkaptonuria was ‘entertained seriously, particularly when dissection demon- strated black material in those spaces (Wells & Maxwell, 1962). Subsequent chemical and physico-chemical analysis ‘of the material, however, found no evidence of the usual type of deposit in alkaptonuric individuals, but instead demon- strated the black deposit was composed of natron and resla, compounds routinely employed by Egyptian embalmers (Wallgren etal, 1986). Pseudopathology resulting from effects arising within body tissue following interment Changes arising from the corpse's endogenous flora, food or enzymes Putrefaction results when anerobic, gasforming bacilli spread through the body's veins postmortem. Soft issues, become Bloated with gas that may also distend the abdomen, seep into the scrotum (resembling a hernia) and feven the’ penis, producing a pseudoerection. Muscular necrosis progresses to tssue liquefaction, stained black by the muscle’s myoglobin. Increased body cavity pressure may squeeze this foamy liquid out of the body’s orifices (‘parg- ing’: Knight, 1991:36), and may force protrusion of the tongue, uterus and rectum from their respective oriflces (Smith & Wood Jones, 1910:219: Zumwalt & Ferro, 1990; Fig. 2.4). These effects can be misinterpreted as forms of antemortem prolapse. Even the abdominal wall, weakened by necrosis of its muscular components, may undergo dehiscence, extruding the abdominal viscera through the defect-The ragged, thinned, tissues at the defec’s edges can be used to separate this postmortem arifact ftom an ante- ‘mortem wound. Fine, sandy soll may enter the bronchi after interment due ‘o soll pressure and the negative pressure generated by the collapsing lungs after death, Diagnosis of pneumoconiosis due to antemortem soil inhalation can be made (Zimmer- ‘man & Smith, 1975) but requires considerable caution. ar- tiles Inhaled antemortem are seldom greater than 10 ‘microns but soil accumulating in the lung after death con- tainsa much greater range of size and is distibution is often recognizably within bronchi or bronchioles. The stomach's digestive juices may autodigest the gastric wall, spilling the stomach’s content into the free peritoneal cavity, tempting an unwary examiner to make an incorrect dagnosis of ante- zortem perforated ulcer. Liquefaction decay of muscle tissue stains the muscle black, When the decay i arrested by desc- ‘ation, the muscle may acquire a black, glistening appear- ance of charzing or resin application. ic, 24 Rectal prolapse. Right legis sorulsted. Note patent vaginal ore (A) ‘beneath and behind wich thelr redundant, rounded mas represents a rlapsed rectum (Ago yar ld enal, rom northern hile’ 20008. Cinchorro cure. ‘Maur. PL.Finally, a comment must be added regarding ficial expres- sions on the bodies of spontaneously mummified cadavers. ‘The literature contains many references to these, often describing them in vivid terms as ‘appearance of terror, sti- fling 2 scream; etc. After death, muscles first undergo a period of hardening (rigor morts) followed by autodiges- tive softening, Such relaxation will permit the mandible and facial muscles to sag, ofien asymmetrically. Wrappings and enveloping cords cause further distortion. Collectively these contortions commonly produce grotesque expressions that are independent of the countenance at time of death. Diag nostic predictions based on such facial expressions rarely have any basis in fact. Changes arising from effects of the interment environment. Soft tissue digestion by fly larvae or by dermestid beetles may result in tissue loss of the nasal areas mimicking syphilitic or leprous processes. One of us (A,CA.) examined a modern forensic case in which the cranial cavity was teeming with fly larvae that had destroyed the entire brain and all meninges and other softtssues within the skull: The body had not been discovered until about 3 weeks after the murder in a house ‘with open windows at summer temperatures, and the insects had gained access by following the track of multiple facial stab wounds that penetrated into the cranial cavity Fuleheri et al. (1986) apparently identified the paleopathological equiv- alent of such a situation in which the larvae were visible on radiography of an Egyptian head (confirmed by dissection). ‘The insects (Kdentified by the authors as Hymenoptera species) had probably reached the cranial cavity via the embalmers' traditional wansnasal craniotomy opening While the forensic lieterature provides litle, if any, precedence for Hymenoptera larvae in human remains, it is conceivable that the unique methods of Egyptian embalming may have made Ls possible, Unfortunately the authors did not document the diagnostic criteria they used for identification of the lar ‘ae, and the ilustation provided is not diagnostic. These authors also found Cyplocoens neoformans in muscle tissue without evidence of tissue reaction, implying this was a post- ‘mortem contaminant. Horne (1993) notes the close similar- ity of Asorcha Berk. spores and red blood cells, and describes the use of potassium hydroxide to differentiate hem. Tendon. stripping by Vultures (Winlock, 1945:21) can be both dra- matic and confusing, Even the retraction of skin in a desiccating cadaver may produce the illusion of postmortem hair growth. Post ‘mortem chemical changes induced by sun and sollwater can decolorize certain hair pigments, resulting in the appearance of red or blonde hair, Usually such color changes are focal, localized to areas of exposure. Condi tons causing all of the scalp hair to change color occur only rarely, SKELETAL ISSUE PSEUDOPALEOPATHOLOGY | 15, ‘These are only a few ofthe many different types of soft tis- sues changes that can occur after death, some of which can simulate ancemortem pathology. The remaining conditions are included in discussions of the pathology of specific ‘organs in Chapter 8, When viewing human remains, whether soft tissue or skeletal, itis usefal to approach a candidate lesion by frst questioning whether the tissue could have been altered by a postmortem process ‘SKELETAL TISSUE PSEUDOPALEO- PATHOLOGY Excavation skeletal a Ofien archaeologists first become aware of the presence of Jnuman remains when their metal excavating tools come into contact with skeletal dssue, Among unsupervised novices inappropriate force with which sucl tools are wielded may result in marred, perforated or fractured bones. In many (but not all) such cases the lack of patina in the fracture will betray its recent occurrence. Rough handling of excavated bones during subsequent transportation ean induce further skeletal damage, especially if bones are placed unprotected Inco containers large enough to permit their movement. Inappropriate methods can also cause commingling of bones at time of excavation or transportation, with the potential for causing unique or incompatible patterns of pathology. cts, Post-excavation specimen handling Exoavted bones are especially vulnerable to commingling during laboratory examination, This is most easily avoided if the labeling of each bone is given highest priority before they are exarnined individually (Well, 19674). Oder rules dealing ‘ith limitations on numbers of skeletons under examination at any onetime ae also useful. It sa this stage that inappro- plate diagnoses are made that result fom lack of awareness of| the range of normal variations. For example, the phenomenon of bilateral parietal bone ‘thinning’ may include a completely penetrating defect. Such defects have been confused with phological lesions including metastatic carcinoma, wepana- tion and other proposed causes. he sternum and olecranon fossa ae other sites where similar misjudgements have been made, Another common point of confusion is differentiation ‘of congenital vertebral fasion from the effect of tama, ‘Scavenger and insect effects Large scavengers may retrieve or at least expose shallowly- buried bodies and actually carry away major body parts16 | PseuvoPaTHoLOsy ‘Smaller animals such as rodents select bone areas that most conveniently fit their dentition Thus, rodents often atack the supraorbital ridges, the created defects of which can resem- ble trauma, or osteitis. Still smaller gnaw marks are often ‘obvious but at times have been mistaken for anthropogenic ‘cat marks inflicted during postmortem defleshing proce- ures (Fulchert etal, 1986), or confused with stone oF metal implement marks that characterize cannibalism (White & Folkens, 1991: 394). Paleopathologists also must become acquainted with the effects of insects whose proteolytic enzyme secretions can liquefy the organic matrix of bone so that, when subsequent groundwater action solubilizes the remaining bone mineral, the localized defects can simulate disease processes. Henderson (1987), for example, recalls cone of the well-known cases of pseudopathology in which several Egyptian skeletons from Naga-ed-der at the begin- ning of this century were reported to demonstrate cranial syphilis, when in fact the erosive patterns represented the postmortem action of beetles, Botanical effects Larger plant roots may invade long bone medullary cavities through biological foramina, and subsequent bone weaken- Jing may result in ultimate fracture. More commonly, how- ever, rootlets will wrap themselves snugly around long bone diaphyses, trapping groundwater benween themselves and the bone cortex, Subsequent lytic action of the groundwater and/or plant secretions can generate surface grooves that can simulate vascular impressions, though their reticulate pat- tem can often be recognizably different from antemortem blood vessel structures (White & Folkens, 1991: 365). Cryogenic and thermal effects on bone Freeze-thaw conditions may shater a buried bone. Thawing conditions permit the accumulation of water within a bone and subsequent freezing wil produce expansion by ice crys- tal formation co a degree that wil fragment the bone steue- ture. Atsites of extreme temperature differences (eg Alaska) such effects on the soil can result in enormous movement of soil masses with as much as 180° rotation, Such an inverting cffet can carry entre skeletons or major body parts with the soll and commingle bones from multiple bodies, producing confusing combinations of pathological lesions. Intense heat can generate equally puzzling changes. Ifa body with intact soft issue is exposed quite suddenly to very high temperatures (eg. house fre) the brain may be vapor- ized while soft ussue stil occudes cranial orifice. The resulting rise of intracranial pressure may be great enough produce skull fractures or even to cause cranium-shattering explosion. An unwary examiner may mistake such effects 28 being those of antemortem violence (Spitz, 1973). Lesser degrees of heat application may cause the dura to shrink with extrusion of cerebral blood into the extradural space between the cranium’ inner table surface andthe contracted ura The incorrect diagnosis of antemortem traumatic ‘extradural hematoma can be avoided by noting the absence of the most common cause of such an antemortem event: a temporal bone fracture that traverses and lacerates the mid dle meningeal artery. Cremation temperatures also produce quite predictable effects on bone that result in fracture-like fragmentation of Jong bones into short, cubular segments. These segments also often fracture longitudinally and frequently cause a curling deformation. Lesser temperature may produce long bone bowing that can be mistaken for antemortem metabolic cffecs of rickets, osteomalacia or even osteogenesis imper- fecta. Natural fires may stain the bones but usually don't reach temperatures high enough (o simulate the changes noted at cremation temperatures. Chemical erosion ‘These effects are mediated in an aqueous environment Hence they are retarded at sites that are well-drained, subject, to lesser precipitation and in temperate climates with neutral ‘or slightly basic soil pH levels (Henderson, 1987). Acid, wet soils can extract so much bone mineral that the bones grossly resemble those with antemortem osteoporosis, Such min~ ceral-depleted bones are also more susceptible to bowing ‘deformation by soil pressure. If the osteolytic process reaches the marrow it may simulate the ytc effects of osteomyelitis ‘The absence, however, ofthe new bone formation that com- ‘monly accompanies antemortem osteomyelitis can aid in the recognition ofthe nature ofthe alteration, Under other circumstances groundwater can actually deposit additional mineral in buried bone. Furthermore, ‘while the chemical form of this is often calcium carbonate, it may be caleium phosphate in the crystalline form of hydroxyapatite, When deposited on tooth enamel, it may have the appearance of dental calculus (Flinn ta, 1987).On the other hand, such deposits on cortical surfaces of long ‘bones may duplicate the appearance of superficial periostitis. Such deposits on the orbital roofs or skull vaule may lead to an inappropriate dlagnosis of cribra orbitalia or porotic hyperostosis, Microbiological agents Bacteria and fungi commonly gain access to the Haversian canals, generating acids capable of dissolving the bone min- eral in irregular patterns suggestive of the histological changes produced by osteoclasts (Ortmer & Putschar, 1985). “Externally the bone surfice may be eroded superficially, pro- ‘ducing a pattern resembling periostts,F.25, Ralogrphicartfcts in mummles. Alldensosin let X ray are sot as Ringed denstesin@) were caked lmph nodes (healed tuberculosis). Pressure effects ‘These forces exert their effect primarily by simple pressure, ‘but may aso erode cortical bone. Bones of varying and com- plex structure such as those of the pelvis, scapula and skull, will yield to pressure deformation or actual fracture in their seructurally weakest areas, while the more dense and uni- formly constructed long bone diaphyses will tend to resist greater pressures (Henderson, 1987; Waldron, 19876). Com- pressive effets of soll pressure frequenty will atten the hol- low cranium sufficiently to simulate antemortem intentional cranial deformation, scaphocephaly or frank fracture (Wells, 1967). ven the thick cortex of long bones can eventually Yield to such mechanical forces. Such postmortem fractures are particularly common among ribs, bat will also often affect the scapula, clavile, forearm and lower leg long bones. Shore tubular bones 2s well as the femur and humerus are more resistant (Well, 19676; White & Folkens, 1991. 358-9). The absence of patina at the fracture site ean offen exclude excavation or post-excavation effects but cannot rule out a change occurring during the perimortam time period. SKELETAL TISSUE PSEUDOPALEOPATHOLOGY | 17 Late pre-Spanis culture ofrortner Chile coast. MAUT. PBL. ‘Wells (19674) laments the frequently mistaken diagnosis of cannibalism made on bones that have been crushed by such postmortem soil pressure. Long bones subjected to bowing deformation without fracture can also be confused with the antemortem effec of rickets. In tis, as well as many of the previously mentioned circumstances the context in which these effects occur (Le the other bones in the skeleton or in nearby skeletons) can be the key to the resolution of the cause (White & Toth, 1991)-An excellent example of exploitation (of a statistical approach to such context data to resolve the antemortem/ postmortem question of defects found in long ‘bone ends isa report by Torbensom eal. (1992). A significant fraction of reported cranial trepanations are in actuality con- ‘genital defects or skeletal dysplasias (in addition to trauma, infections, tumors and hematopotetie disorders). Radiological pseudopathology Wels (19670) note that deceptive denses in rdology can Be mideading in sere ways (Fg, 23) includes theappearance of a density resembling dental calculus that is actually due to sand located between two teeth roots; erosion of mastoid septa by postmortem processes that simulate the radiological appearance of mastoditis; and crystal deposits 4m sinuses may mimie osteomas or sinusitis. In addition post- ‘mortem sie deposits can increase the radiological density sufficiently to resemble osteopetrosis.PART THREE Traumatic conditions Both accidents and certain cultural activities can lead to tau- ‘mati skeletal or soft tissue injuries. Our interest in identfca- tion of these lesions stems from our recognition that they provide important information about an ancient population's practices dealing with war, interpersonal viclenc, knowledge about the terrain and other aspects of daily lif. However, various authors have interpreted the available evidence difer- cently; Meiklejohn etal. (1984) suggest that substantial iffer- fences in the frequency of traumatic lesions between ‘Mesolithic men and women more probably reflect differences in labor division and therefore chat such lesions are of an accl- ental origin. Campillo (1995) feels that injuries of violence were no more frequent among the hominid austalopithe- ‘ines than among modern primates (other than man). How- ‘ve, evidence of human violence became increased detectably uring the Mesolithic period while the Neolithic was charac- terized by an unmistakable rise in arrow or other sharp- pointed lesions that were the product of cultural practices such as war and ritual, Furthermore, Wells (1964) feels that skeletal injuries fiom violent blows are recognizable as cary s the Paleolithic, and Dastugue & Gervais (1992) inter- pret the pathology among even the australopithecines and Pitheantbopus as well a8 Cro-Magnon remains as reflecting bates of extermination. “The most popular interpretations suggest that inerease in population size is accompanied by competition for resources ‘with resulting interpopulation warfare. Merbs (1989), for example, suggests that... useful to look at trauma in the broader context of human behavior, such as circumstances that produce wauma the effects on the individuals and pop- ‘lations, and medical efforts to heal the results of traumatic sues... Paleopathologists aré particularly interested in the changes of human trauma pattems overtime (Manchester, 1983 11; Ormer& Putschar, 1985). Of considerable anthro- pologie interest also isthe evidence provided (by massivehealed fractures) of cooperation and support provided to the nonproductive victim during the period of immobility nec- essary to achieve healing (Aleiat eta, 1987) SKELETAL EVIDENCE OF TRAUMA Fracture A fiaccure Is dlscontinulty of or crackin skeletal issue, with, or without injury to overiying soft issues. External forces that exceed the natural suain or elasticity of the skeletal seructure ae applied directly or indirectly to bone Mechanisms “These include: Feexion (bending). Force i applied perpendicular to the Jong axis ofthe bone producing angulation with a trans verse or oblique fracture line beginning atthe convex sur- face extending toward or as fara the concave Shearing Two opposite forces perpendicular to the diaph- ysis resulting in a horizontal fracture line. 3. Compression, Force is applied inthe axial direction, such as ina fall, resulting in crushing or impaction of skeletal tissue, charactersticlly i the vertebrae 4. Rotation, twisting or torsion Similar to shearing butin che same plane as the daphysis, producing a spiral facture. “action or tension.A violent muscle contraction (such as in epileptic seizure) may tar off (avuls) a smal irregu- Jar fragment of bone atits tendon insertion into bone, sometimes accompanied by joint dislocation, Pathology ‘Total skeletal discontinuity characterizes complete fractures, \ith or without displacement of the rw fragments (Fig 3.1); Doth surfaces of a flat bone are involved. In incomplete frac” tures bone crack does not extend the fll ngth or thickness ofthe bone and hence no displacement occurs These are com- ‘mon in children, especially the ‘greenstick’type in which one cortical surface is buckled or crumpled, Similarly a compres sive effect may involve only one side of the bone (‘torus or ‘buckling’ type of facture.) Comminuted fractures result in ‘more than two fragments (a special ‘butterfly’ fragment effect, ‘may involve two bone fragments with a triangular, buterly- shaped third fragment between them). In a dosed or simple fracture the overlying soft issues are intact while these are ac erated in a compound or open fracture. The latter obviously often becomes infected, recognizable in the paleopathological state as an area of bone surface irregularity with pitting (Manchester, 19830: 55) These are especially common in chil- dren, inte-articula fracture is seliexplanatory and is often complicated by subsequent degenerative joint disease Stress or faxgue facrures ae the consequence of repeiive frees gen ezating microftactures whose cumulative effect eventually leads to complete fracture through the bone cortex (Bullough, 1992). Bramples include long-disance running or long arches by soldiers The feet (distal second metatarsal or cal news) are most commonly alfected othe upper tied of the bia followed less often by the Femoral neck, distal femur dia- physis, pubic rami and lower fibula as well as (in children) rnetaphyses In the upper limbs (usually radius or ulna), ribs and clviles such facrres have been identified as occupation ally-rlated to day pigeon shooting or forking farm manure (Revell, 1986). The erm fanigue’ fractures is applied to simllar tout more minor, hairline fractres without displacement that are initiated by osteoclastic resorption and periosteal callus Periostal new bone formation in a more major sess facture may be so exuberant chat it may actually mimic a malignant neoplasm, although the presence ofa fracture line can help csublsh the waumatic nae of the lesion (Aegerter & Kirkpatrick, 1975). Pathological fractures reslt from forces no greater than common, every-day stresses that are applied to an azea of bone whose structural integity has already been compromised by a local pathological process. Such local Fe. 3.1 FactureFemut, Note huge clu, shortened phys. Meco duit, Catalonia, Spain .23. Courtesy DD Campi, MAGeffeces may be due to the lytic action of a neoplasm, osteo pporosis, cysts, infection, developmental anomalies, endocrine effecss (hypoparathyroidisin), neurological disorders (tabes dorsalis syringomyelia) and even excessively dense but bride bones including osteopetrosis and Page's disease. While usually obvious, the original lesion’s effects may be obscured by the healing process, making diagnosis dificult. Fracture repair The admirable sequence of events following fracture that results in restored function has been called a great success of nature (Bullough, 1992). It is characterized by initial hematoma formation that is organized into a fibrous mass (fibrous callus) uniting che tissues into a fragile union, with subsequent caleifcation and finally remodeling into normal bbone. The acute hematoma at the fracture site coagulates in 6-8 hours after which an outpouring of cells (inflammatory stage) and their differentiation into fibroblasts, chondrocytes and osteoblasts together with vasculoneogenesis initiates repair at the external periosteum. The reparative stage is char acterized by a fibrous union achieved by the third week which Fe 3.2, Pseweartrasis, Interpol so tisuepabe- Diy provented uineton ofeaus of femur acre ends Mager adit. No, 3M Courtesy 6. Warden SKELETAL EVIDENCE OF TRAUMA 4s then calefled by mineral released from the bone fragments; canilage is replaced by skeletal tissue. The remodeling of the calls into mature skeletal histostructure and normal anatomy 4s the slowest stage, requiring up to an additional 6 weeks in children or 6 mouths in older adults. Factors, in addition t0 age, that influence healing rate are adequacy of vascular supply, fracture type (horizontal heal slower than spiral fractures), bone part (bia is slowest, metaphysis fastest), soft tissue interposition (retards), and bone nature (cancellous bone rapid, cortical bone slower, with or without externa callus for- ‘ation). Immobilization is paramount because mobility stim ‘lates fibrous callus formation that requires longer healing time. Infection delays healing as does any underlying patho- logical process that may have led tothe fracture. The complex- ity of the healing process requires good general health and ‘nutrition to achieve the most rapid healing response. Fracture complications, ‘Acute fracture complications depend on the extent of frac- ture and related soft issue injury and include shock, hemor- rhage, fat embolism (liquid fat from crushed adipose tissue Fi. 3.3, Pseudoarthoss, United humerus atures apparent Ine upper am deformity nso ier ofS. Chi Wat. Prtograp 89. NMA. Courtesy Pega,sucked into lacerated veins), thromboembolism, secondary {infection with septicemia including gas gangrene (see Chap- ter 7) as well as cardiac and pulmonary problems. Local effects include the following 1. Delayed healing. This term must be adjusted to expecta tions forthe particular fracture type involved (Watson Jones, 1980), modified by factors listed above 2. Pseudoarthrosis. The bone ends are joined only by Abrous tissue and a fibrous pseudojoint envelops the bbone ends (Fig. 3.2 and 3.3), Rare among children, itis ‘most common in young adults, Factors favoring its pro- duction include interposition of soft tissue (periosteum, ‘muscle, cartilage), excessive separation of fractured frag ‘ments, deficient blood supply and especialy lack of ‘immobilization (Watson-Jones, 1980).The fractured ‘ends become rounded with sclerosis of the medullary cavity, Demonstration of such sclerosis is useful because it {is responsible for cessation of che healing cellular response, In antiquity, nonunion was common in the proximal femur and in forearm bones (Manchester, 1983e: 57). In paleopathological specimens confusion between pseudoarthrosis and amputation may arise ifthe distal segment undergoes resorption (Merbs, 1989) as the fracture through the olecranon fossa ofthe right humerus of Shanidar I (a 60 000 year old Neanderthal skeleton from Shanidar cave in Iraq (Trinkaus, 1983)) demonstrates. Among the Guanche population of Tener: ife, Rodriguez-Martin (1991) found all cases of olecranon process healed with the production of pseudoarthrosis 3s did half of those ofthe tibial malleolus. This complication is much less frequent inthe radius midshaft where itis ‘commonly related to an ulna fracture 3, Poor alignment. The powerful muscles attached to the fernur cause this complication to be the most common site of fracture complications observed in paleopathology. ‘Among the Guanches all femur fractures healed in mis- aligned status (as did tibia and radius fractures: Fig. 3.4) 4, Bone shortening. Multiple causes include poor align ‘ment with marked angulation or fragment superimposi- Udon as well as bone loss (compression, comminution) and epiphyseal growth disturbances in children (Adar, 1986), Lower limb shortening of as little as 2 cm can cause significant clinical dysfunction. 5. Osteomyelitis. While simple, closed fractures occasion- ally become infected hematogenously, post-fracture ‘osteomyelitis is primarily associated with compound ‘fractures. Their paucty in paleopathological reports (Ormer & Putschar, 1985) may reflect the scarcity of ‘compound fractures in antiquity. 6, Avascular necrosis of bone. Insufficient blood supply ‘can cause necrosis ofthe affected bone with subsequent resorption. It occurs more frequently near bone ends, such as the fernur head following a fermur neck fraccure, the proximal end of the carpal navicula, the talus or even the entire lunate, Peudoarthrosis or severe degenerative joint disease may be the final deformity of this complica tion, Traumatic interruption of blood flow in a child’s growing bone can lead to bone shortening. ‘Neuropathy. Nerve damage leading to lack of pain sensa- tion may encourage use and mobility ofa fractured bone, retarding healing or leading to a Charcot joint (Ortner & Putschar, 1985), Articular changes. Direct injury to joint surfaces can cause severe degenerative joint disease alterations even leading to bony ankylosis. These alterations may so closely resemble those of osteomyelitis that Morse (1978) has suggested thatthe presence of a fracture inthe affected bone and lack of bilateral symmetry can assist in thelr dif {ferentiation in archaeological specimens. Fic 3.4 ature, ws (Call's). Poory aligned, welt healed dul female {anche 8.0 000, Canary islands 6.6, ANC,Paleopathologic study of fractures in dry bones Definite evidence of healing is the most useful criterion for the determination of the antemortem or postmortem nature of a skeletal fracture. Slight rounding of the fractured edges with a polished appearance when viewed microscopically is the earliest sign of healing (Maples, 1986) but at least 7-10 Gays of antemortem healing are required to reach a satisfac- tory degree of certainty. Working witha collection of modern bones with known provenience, Mann & Murphy (1990) felt that 2 weeks isa workable minimum interval of post-fraccure healing change recognition. Maples (1986) also notes that the elasticity of living bone is due to its water and protein (collagen) content and is responsible for the difference in fracture patterns among antemortem and dry bones. Green- stick and skull fractures with concentric, radiating or stellate appearance as well as depressed skull fractures are seen in bones with retained elasticity while postmortem fractures of dry skulls show smaller fragments and dry long bones show irregular edges, disappearance of small portions of bone and litle beveling, Bone elasticity Is, however not los instantly at death, but is, instead, a gradual process dependent on specific ‘aphonomic features. The ‘perimortem’ period during which jout evidence of healing but with fearures sug. gesting the pattern found in bones with retained elasti can range from 2 weeks before death until a varying post- mortem interval of at least 2 months. ‘Ortner & Putschar (1985) also remind us that childeen’s fiactures may remodel so completely as to obliterate evi- dence of previous fracture, and that differentiation of acci dental trauma from that of interpersonal violence can be -very difficult, aided by location and pattern of the lesions. Finally, while well-aligned Jong bone healed fractures in ancient humans are not common, Schultz (1967) found that ‘most limb fractures in wild gibbons healed without sufft- a fracture Fe. 3.5. ania fracture, perimartem. ight parietal ature No healing. Adult male ‘anche, ca. AD. 190, Canary stands Sg bal injury? Gi. MAT, OANC. ‘dent malalignment to cause dysfunction. For that reason itis probably not appropriate to credit the application of medical skills fora similar finding in an ancient human. Skull fractures and crushing injuries General Principles Although scalp lacerations, cerebral contusions, and both epidural and subdural hemorrhages occurred in antiquity, these leave litle certain evidence in dry bone skeletons, the injuries of the skull in such skeletal samples ae largely limited co fractures. Oddy, the correlation between the size or extent ofthe fracture and the degree of injury to the brain {snot great, While many crushing inuries ofthe skull show xno signs of healing, many paleopathological skull fractures demonstrate evidence of recovery. Clearly, some ancient pop ulations developed a system of soclal support for such afficted persons (Adelson, 1974). A universally accepted classification for skull fracrures as not yet been developed. While Steinbock (1976) feels that both accidental fills and blows could have been responsible for skull fractures in antiquity and DiMaio & DiMaio (1989) ‘group skull fractures into those acquired by blows and accel: cration/deceleration injuries secondary to sudden ead movements, most authors find it dificult to differentiate Dbecween these causes in dry bones. Furthermore, what evi- dence there is, suggests that blows are by fr the most com: mon, Thus, most predominance of skull fraccures in males and location of the lesions on the lft side of the cranium, implying the pathol ogy was acquired by a face-to-face encounter with 2 right- handed opponent. In fact Courville (1967) classifies skull {injures on the basis of the differing nature of the fractures produced by weapons of varying shape: —Sharp-cdged incisions (metal o flint axes) Penetrating wounds (pointed and hafted weapons) Linear fractures (bunt, small weapons) —Gross crushing injuries (arge stones or clubs) studies demonstrate a substantial Etiology, mechanisms and pathology A sequence of events leading to a major skull facture has been described as including () skull indentation without fracture, (i) inner table fracture, (J) both outer and inner table fracture (Fig 3.5), (iv) depressed fracture with Iocal- ized comminution and (v) outer table crushed into diploe (Gordon etal, 1988). Factors modifying the nature of the skull facture include the physical characteristics of the impacting object (shape, size, composition), its velocity, presence and thickness of overlying soft clssues and the skull location of the impact site. In general, low velocity injuries affect a broad area and generate linear fractures while the energy of high velocity impacts is often focused on smaller 2324 | TRAUMATIC CONDITIONS areas causing depressed fractures (Stewart, 1979). Local fearures influencing the appearance of the fracture include bone thinning to accommodate large Pacchionian gramula tions, aberrant veins and thickening of the diploe or ables (Gurdjan e al, 1950), Fractures passing along suture lines, ‘common in young adults, may not be easy to differentiate from postmortem bone separation (Maples, 1986). Several types of events may complicate a fracture. The sharp-edged inner table fracture may lacerate the underlying brain causing severe intracerebral hemorthage. Laceration only to the depth of the meninges may be followed by for ‘ation of fibrous adhesions between meninges and brain that manifest later as post-traumatic epileptiform seizures Infection may be the direct result of introduction of contam- {nated skin, soil or impacting object in the event of com- ‘pound skull fractures, while infection ofthe scalp soft tissues ‘may extend down to the level of the fracture in other cases. If the skull fracture is comminated, the infection may prevent consolidation of all of the fragments during healing, result- {ng ina defect that could be misdiagnosed asa trepanation in a dry bone skull (Adelson, 1974), Paleopathology Cranial fractures have been identified in Homo ercus and probably in Autolpthex. Innumerable case reports and pop- ‘lation studies abound inthe paleopathology iteature. Most of them identify a high male/female raio usually inter- preted as evidence of group conflict, though Manchester (19834: 59) has suggested that it could also reflect a division of labor with males performing the more hazardous manal labor When a igh left/right site ratio is encountered, fae- to-fice conffontations appear the most probable explana- tion, By far the most common injury isa concave indentation of the outer table. Such a healed, frontal, outer table depressed skull ractare found in an ealy fourth century BC Samaritan has been given the sobriquet ‘Goliath injury’ by Bloom & Smith (1991) because of is similarity to slingshot Injuries, Similar such lesions are seen so commonly in some Peruvian skull collections that they have earned the cog ‘nomen 70 caliber lesion’ because their average diameter Is about 70 mm and smoothed stones of that approximate diameter have been found in the area that may have been ‘employed as sling ball aimmunition (Zimmerman et a, 1981). An early Bruscan body (eighth century B.C.) from the Tarquinia area is an excellent example of violence in antiquity, revealing multiple fractures of ribs, scapula, ulna and hands as well as a probably lethal massive crushing {njury of the temporal Bone all of which appear to have been inflicted simukaneously (Mallegnt eta, 1994). Several examples of population studies also demonstrate the type of information about ancient human behavior that can be extracted from an examination of canal fracures in amarchaeological population. Rodriguez-Martin etal. (1993) studied skulls ofenerif’s (Canary Islands) aboriginal popu lation (Guanches), and found cranial fractures in about 9% Of those from the southern slopes but only about 2% from the island's northern side. The male/female ratio was about 2/1 and most of the lesions were in the frontal and parietal bones. The bulk of the lesions were healed and only 17% ‘were identified within the perimortem period. The island is, characterized by steep-walled, voleano-formed valleys that tended co separate the island's subpopulations. These invest ‘gitors interpreted the findings as evidence of group vio Tence, supported by ethnographic accounts of common intervalley warfare. In a similar study by Walker (1989) of Native American remains on channel islands and adjacent mainland of southern California, about 22% of the island populations showed healed, depressed fractures of the skull’ ‘outer table. While mainlander populations averaged about 3%, Walker attributed the difference to intense competition for the islands’ limited resources and suggested that a subse ‘quent decline in lesion frequency among the islanders was coincident with the introduction of the bow and arrow. Vertebral and thoracic fractures Etiology and pathology Force sufficient to fracture a vertebral body may be inflicted cither by a forward shearing stress associated with hyperflex- {on or by a vertical compressive force (e.g, toboggan injury) thai can create a ‘telescoping’ deformity (Merbs, 1983) ‘Although these can affect any part ofthe spine, dhe bodies of the lumbar vertebrae are most frequently affected. The shear- ng fractures are especially prone to compress or lacerate the spinal cord with resulting paralysis and urinary bladder infection. They also can generate a substantial hematoma ‘with a generous quantity of callus surrounding the fracture (Fig. 3.6)-The vertical compression may affect the entire ver- tebral body uniformly, although the additional support imparted to the posterior part of the vertebral body by the Fie 36 vertebra fracture. ith umbervets cure, Large calls on venta arpet Acuttmale,Cibaya culture coastal souher Peru 2... 150, PALneural arch elements causes the anterior (ventral) ends ofthe vertebral body to be more vulnerable to compression. This results in a wedge-shaped vertebra, flatened to 2 greater degree anteriorly The consequent misalignment produces a forward bending (kyphosis) of the upper trunk, the degree of which is related to the difference in compression between the anterior and posterior ends of the vertebral body, Ifthe trabecular bone structure of the vertebral body has been ‘weakened by a disease process such as that of osteoporosis, the degree of compression can be major and multiple verte- brae may be involved, resulting in a crippling degree of kyphotic deformity or mulkiple vertebral collapse (‘con- certina fracture’). The periosteal new bone formation is commonly of lesser degree in compression fractures and usualy is limiced to small nodular areas that fuse adjacent vertebrae. Since perlosteum does not cover the vertebral body surface facing the intervertebral disk, reactive changes aze usually found along the periphery of the disk adjoining the vertebra ‘Most rib fractures are not displaced and, although painful (ibs can not be effectively splinted), usually heal unevent- full: Massive thoracic crushing injuries (e.g steering whee! impaction in auto crashes) may displace fractured rib frag ‘ments whose sharp edges can lacerate the pleura, lung or hheart with serious consequences, Paleopathology ‘The telescoped type of vertebral compression fracture has been described in archaeological human remains frequently (Wells, 1964). Their high frequency in North American Inuit (Eskimo) populations nas led Merbs (1983) to suggest they ‘may have been acquired by the violent jarring to which such natives are subjected when riding their dog-powered sleds ‘over rough ice, While massive thoracic crushing injuries carry with them a significant mortality, Wells (1964) describes an ancient skeleton whose fractured right clavicle as well as 6 right and 10 left ribs had all healed with many areas of fusion between adjacent ribs. Dislocations (luxations) Definition and pathology A dislocation (luxation) consists of the complete and persis tent displacement of the articular surfaces of a joint’s bones, ‘with partial or complete capsular and/or ligament rupture. ‘The term subluxation is applied to identical changes but of lesser degree. The gravity of a dislocation depends upon the joint involved, the degree of dislocation and its duration. Factors influencing the tissue changes include loss of syn- vial fluid with its reduction of nutrition available to the joint cartilage and impairment of blood supply to the joint elements. The trauma inducing the dislocation may also SKELETALEVIDENCE OF TRAUMA |. 25, result in soft tissue laceration suflicient to expose the joint, inviting infection. Ischemia may be severe enough to cause avascular necrosis. Persistence of the dislocation produces the more long-term changes of accelerated degenerative joint disease and bone atrophy secondary to immobilization. Force sufficient also to induce a fracture extending into the joint exaggerates the effect of these complications and may render the joint vulnerable to subsequent dislocations. Paleopathology [Because the inldal lesion of dislocation involves principally soft tissues, the diagnosis of dislocation in dry bones is, dependent upon subsequent skeletal alterations that are sec ‘ondary to the bone displacement. Since these require a con- siderable interval of time for development, the dislocation ‘must persist to produce them, For the same reason itis prob- able that dislocations of lesser degree will go undetected. The dislocation sites most frequently identified in archaeological bones are the shoulder and the hip. The shoulder’s depen. dence upon the joint capsule and ligament to attach the humeral head to the glenoid cavity makes it vulnerable to dislocation. However, it also makes it one of the easiest co reduce (Le. to restore to normal position), thus ameliorating its effects (Merbs, 1989); it is probable that this was done frequently in antiquity. Persistence results in easily recog- nized changes of development ofa filse cavity on the scapula Fie.3.7 Dlsocation, elbow, Degenerative changes, upperanculr surface, tina Adultmale Guan, c. AD. 10, Canary lands. 0. MAT, OANC.26 | TRAUMATIC CONDITIONS. and distortion of the humeral head. Steinbock (1976) has identified reports of this dislocation from Neolithic France, the Early Bronze Age of Greece, Britain's Anglo-Saxon, Bronze and Medieval periods as well as late Archaic interval in Illinois and early burials in Hawa Hip dislocations have also been identified repeatedly in archaeclogical bones. Attempts to form a false (secondary) acetabulum on the ilium are often recognizable and the femur head is commonly distorted. Because the ligamentum teres also contains blood vessels, its injury may induce sufi cient ischemia to cause avascular necrosis ofthe femur head with its subsequent distortion of the head's morphology. Disuse atrophy of the leg bones may follow-The obvious con: dition from which traumatic hip dislocation must be differ- entiated is congenital hip dislocation, This can usually be achieved by close inspection of the acetabulum because, except for some new bone formation, this seructure is nor- ‘malin the eases in which trauma is responsible for the dislo- cation while in the congenital form the acetabulum is obviously malformed ~ small, shallow and triangular. Blondiaux & Milo (1991), however, feel they can detect the hip dislocations of more minor degree (subluxation) on the basis of a notched, enlarged and slightly more shallow acetabulum accompanied by femur head remodeling, since in these milder cases the femur head is not dislocated com- pletely out ofthe acetabulum. Other joints whose dislocation has been identified in ancient human skeletons include the acromlodlavicular, elbow (Fig. 3.7) and ankle (Fig. 3.8) joints. Dreier (1992) reported one of the few cases of finger (fifth) dislocations in ‘which the right first and second phalanges were dislocated, the second and third demonstrated lateral slippage upward and backward about 10 mm upon the dorsal surface of the first phalanx with joint ankylosis, ‘An uncommon dislocation was identified by Rodriguez Martin (1992) in a Canary Island aboriginal (Guanche) young adult male with a left subtalar dislocation probably: acquired in a fall among Tenerife’s rocky, aid slopes. Osteo- phytosis, eburnation and porosity and pseudoarthrosis iden- tified the presence of degenerative joint disease (DD) in the Jefé talus and caleaneus as well as mild changes or DID in the distal bial articular surface, The presence of severe spondy- losis involving vertebrae fromT3 to L3, probably the conse quence of a limp secondary to the ankle lesion, testified to the prolonged survival following the dislocation (Fig, 3.8) Traumatic myositis ossificans Definition and pathology ‘Myositis ossificans traumatica is usually produced by avul- sion of tendinous and/or muscle attachment to bone (occa sionally by crushing injury of muscle against bone) generating a hematoma. Because of the proximity of hematoma to the bone's injured periosteum, the periosteum ‘may participate in the organization ofthe hematoma includ {ng not only calcification but ossification as well. The result- ing calcified and often ossified mass of woven bone constitutes the lesion known as myositis ossifleans traumat ca (Fig 3.9), Most commonly involved sites are elbow, fernur (linea aspera), shoulder and pelvis. In spite of itszname, itis not a primary inflammation of muscle but is instead, of traumatic edology: additionally ossification Is not invariable and is dependent upon its proximity to the perios- teum (Watson-Jones, 1980). It should not be confused with the congenital condition termed myositis ossifcans progres- sva, nor withthe process of heterotopic ossification Myositis ostifcans traumatica may occur without obvious seletal injury (Apley, 1981) and after only wivial muscle trauma, Minor rauscle trauma may led to metaplastic bony bridging of hip joints in paralyzed patients (Ormer & Pusschar, 1985). Ectopic bone unatached to ary bone may develop within muscle Differential diagnosis must also sepa- rate tis esion from an osteochondroma and exostosis. The Inter is usually smaller, often is related co the epiphyseal ine, growing perpendicular to the plane of the dlaphysis and fre quently contains a rounded cap, quite unlike the irregular cossified mass of myositis ossifcans traumatica. Osteochon- romas are often iregula, but usually more cousely lobular and commonly demonstrate an obvious relationship to their ‘origin in bone. In the shoulder joint acute ossifistion of ‘capsular tissues produced by hydroxyapatite crystal deposi- Fc, 39. Myositis oasifians traumatic. equa caleledrasss acheret ‘oterium @) and fer (probably represent calcited crushed muscle Late precontect midwestern U.S.A aboignal and medieval adult Spain (@. courtesy ohn Gregg aré USDAL) (photograph by Glenn Malchon) and: Campi), MAL. SKELETALEVIDENCE OF TRAUMA | 27 tion by an inflammatory reaction can present a confusing senilarity, but its restriction to the Joint capsule can usually separate the possibility (Watson-Iones, 1980) Paleopathology Perhaps the most well-known example of this condition is that ofthe hypertrophic bone development on the left fermur ofthe Java pithecanthropus, a Hom erectus, Ortner & Putschar (1985:70) demonstrate several well-illustrated lesions Localized subperiosteal thickenings ‘Blunt trauma, most commonly to the anterior tibial surface, the radius, fibula or ulna, will frequently generate a subpe- riosteal hematoma that subsequently is almost invariably cossified by the overlying periosteum (Watson-Jones, 1980). ‘These are common in archaeological populations and can ‘easily be differentiated from reactive changes to treponemal, infection by their very sharply localized periphery and the {identity of thelr color and texture with that ofthe surround {ng bone (Mann & Murphy, 190). Skeletal injuries by weapons Pointed and bladed weapons ‘As would be expected, pointed weapons generate a perforat ng, often conical puncture whose smooth, sharply-defined edge can be used to distinguish it from postmortem erosions if excavation tool defeess ean be excluded on the basis of color and patina differences. Flat-bladed instruments (Knives, machetes, axes) produce elongated, V-shaped grooves, though allowance must be made for the tendency Of bone elasticity to effect partial wound closure after the {instrument is withdrawn (Maples, 1986). Valuable informa- sion about the inflicting weapon can be extracted from a scanning electron microscope study of an incised wound carried out either directly on the bone surface or om a resin cast ofthe wound, Paleopathology Study of Middle and Late Woodland NativeAmerican archaeo- logical populations from Mlinois revealed projectile points and fragments in 24% of the individuals’ bones and body cavities, suggesting warfare played an active role in these ‘groups’ activities (Cook, 1984). However, the paleopathol- ‘ogy literature contains far more case reports of these wound, types than population studies (Pig, 3.10). An early Neolithic adult male skeleton from Denmark had one arrowhead in the maxilla and another in the sternum. The latter's position suggested it may have produced a fital, exsanguinating28 TRAUMATIC CONDITIONS laceration in the proximal aorta (Benaike, 1985).A wooden arrowhead was found to have penetrated a thoracic vertebra in 2 Canary Island aboriginal toa depth sufficient to have lac- crated the spinal cord (Diego Cuscoy, 1986). A Bronze Age Basque skeleton demonstrated asilex arrowhead in the pelvis with evidence of healing (Btxeberria & Vegas, 1987). The skull of a 1100 year old Native American from Ohio revealed a projectile point had penetrated the facies infratemporalis of the maxilla, waversed the sinus and reached the anterior sur. face just below the infraorbital foramen; healing changes indicated the individual’s survival (Sciuli et el, 1988). An Arizona Native American skeleton had a small lithic point ‘embedded in the cuneiform bone with surrounding bone 6, 3.0, Arowhend inary. (2) (Obsidian point early 17m ong, ‘embedealin body ofthe ithlum- bar vertebra (@) CT scan No ev enceohealing Young adult female, (0500-1700) central Cale fomia se, Al-329. Courtesy Or Rober lurmain Fie 3.22, Gunshot fracture. Lead srustetball row) Instat elbow fracture S.C War sod. HM (Courtesy 6. Worden, resorption without infection, and another had a healed sinus defect suggestive of an untipped arrow wound (Merbs, 1989). An arrowhead was also found embedded in the twelfth thoracic vertebra ofa Neolithic skeleton from Catalo- nia, Spain in a position implying it penetrated the aorta and caused fital hemorthage (Campillo, 1993). Four adult male skeletons from Navarra, Spain showed a healed, incised rib wound and unhealed arrowhead wounds of the maxillary sinus and right humerus as well as an arrowhead within the vertebral canal that must have macerated the spinal cord (Armendariz eta, 1994), Gunshot wounds {A derailed description of the forensic aspects of skeletal gun shot wounds is beyond the scope of this book. Attention can be called to certain basic features (Fig. 3.11). These include the fact chat entry wounds ofthe skull are commonly small circular and discrete with inner table beveled edges while the exit hole is larger, irregular, often with comainution and Joss of some fragments as wel as outer table beveling This is laxgely the consequence of transmission of the bullet's energy into intracranial pressure increase, though bullet fragmentation may modify these features and even generate ‘more than one exit wound. Intracranial angulated bone sur- faces may also cause the bullet or its fragments to deviate from its primary path. Examination of a skeletal defect radi- ‘graph with a magnifying lens may identify metal fragments that establish its gunshot nature, Castellano Arroyo (1994) ppoints out that such other variables may produce several types of fractures and defects: | Incomplete fractures with radiating fissures that stop at the skull sutures 2. Prominent, discrete holes with fissures that radiate per- ppendicular tothe defect margin; 3. Irregular large holes typical of short distance gunshots generating an explosive intracranial pressure,Paleopathology ‘An early owentiet» century North AVfican Bedouin male skeleton was found to have an 8 mm lea bullet chat entered the skull below the left orbit and became embedded in the ‘ase of the skull adjacent to the foramen ovale near the carotid canal and jugular foramen, with changes suggesting the ad survived it for at east month (Irish ea, 1993). In another body a 32 caliber bullet was embedded in a rib (Méerbs, 1989) while Wells (1964) describes a Native Ameri- can witha ficial gunshot wound that had healed. Decapitation Pathology “The stigmata of decapitation are the eut marks on or through cervical vertebrae and often, but not invariably, separate burial of the skull (Merbs, 1989). Severance through any of the cer vical vertebral has been reported, but the midcervical area is the most frequent transected site. Horizontal blows often include portions of the skull (especially mandible and skull, base) in the transection plane (Manchester, 19830: 60). As is ‘rue in other parts ofthe skeleton, it is not easy to determine ‘whether lesions assigned to the perimortem period were inflicted premortem or postmortem. Surprisingly, expect- tions that the mortuary context would provide clues to the special social stans of the decapitated individual frequently are not flfiled (see below). These problems are compounded by the fac thatthe lesions, especially those ofthe skull and ‘mandible, often mimic postmortem erosive alterations Paleopathology Decapitation of an adolescent female from the Romano- British cemetery in Hertfordshire had been caried out atthe level of the second cervical vertebra via six separate cuts, believed to have been performed postmortem, principally because of the absence of special mortuary treatment (McKinley, 1993). However, six bodies from the Romano- British cemetery at Cirencester (believed to represent retired legionnaires and Roman official) all demonstrated decapita- tion at levels from the second to the fifth cervical vertebrae In all, the heads had been placed in the normal anatomic position in the grave and, except for the fact that two graves each contalned wo decapitated bodies, no distinguishing mortuary feature unique to these burials could be identified (McWhirr eal, 1982:108-9). Seven additional decapitated skeletons were found in the nearby Lankhills cemetery Decapitation was nota common form of Roman punishment (Bush & Stiriand, 1987). ‘An additional case from the Viking period in Denmark was probably performed by a horizontal blow atthe third cervi- cal vertebra level that also included the inferior aspect ofthe SSKELETALEVIDENCE OF TRAUMA |. 29 ‘mandible in the wansection plane. Additionally two female skulls from Denmark's Room Bog and Stidsholt Bog aso reveal transection through the second and third cervical ver- tebrae respectively (Bennike, 1985). This author also describes the last forensic decapitation in Denmark about 200 years ago in which the head had been displayed on a stake asa public reminder. ‘Other decapitation examples include an Iron Age specimen from Suwon Walls (Brothwell, 1981); a 25 year old male ‘mummy from northern Calle that also included other coepo- real violence and in whom decapitation may have been per- formed postmortem to acquire a trophy head (Allison & Gerszten, 1983) and several New World reports from Meso- america (Moser, 1973) and North America Riding, 1992). Strangulation Pathology Evidence for manual strangulation in recently deceased bod- {es slargely limited to fractures of the hyoid bone and of cal- cified thyroid and cricoid cartilages as well as bruised local cervical soft dssues (Stewart, 1979; Concheiro Carro, 1994), Im skeleronized bodies the cartlaginous fractures can only be detected if they are caeifed, so that such 3 diagnosis is more apt to be made among the aged. Nonmanual (rope, rigid items) strangulation may result in cervical vertebra facture including hairline transverse fractures on or posterior tothe superior articular processes ofthe axis. Paleopathology ‘The few paleopathological reports of strangulation are pri- ‘marily in the forensic literature (Stewart, 1979). Perhaps the ‘most well-known example isTollund man, 2 bog body from. Denmark who was found with a rope tied tightly around his, neck (Bennike, 1985). Angel & Caldwell (1984) diagnosed death by strangulation based entirely on a fracture of the transverse process of the sixth cervical vertebra in a young, ‘white female. Amputation: the skeletal evidence ‘Methods and pathology Circumstances under which amputations occurred in antiq- uity include soctal justice (punishment), accidental and war injuries, deliberate surgery and ritual. The latter probably was limited to finger and/or toe amputation and is discussed in the section oa soft sue injuries below, Amputation as pun- ishment is well documented among some cultures even today and Brothwell (1967) seems sure that hand and foot removal ‘was practiced during the Saxon Period in Britain (Fig. 3.12)30 | TRauMaric CONDITIONS Fi. 3.12. Amputation.) Bilateral forearm amputation, healed (punt?) (Mater amputation. Healig changes. tltary wound} 25033, 2D. 500, Spain. @) Mader. () Courtesy. Turbor, M Hernan, E.Chimenos&D. Campi, UB, CNT 1 seems self-evident that sword and ax war injuries were capable of limb severance, though accidental amputations of ‘major limbs must have occurred in antiquity only rarely ‘An understanding of the physiological sequence of post: amputation events can be useful for the solution of the com- ‘mon problem facing paleopathologists in these specimens: the separation of amputations from simple pseudoarthrosis. Post- amputation survival of less than a week produces no detectable signs of healing This i followed by vascular erosion of the bone ends and adjacent diaphysis. By the fourteenth ppost-amputation day an endosteal callus becomes apparent; ths progresses to narrowing and finally obliteration of the ‘medullary cavity atthe bone end with rounding and smooth ing of the stump. Localized osteophytes may develop and finally bone atrophy secondary to disuse may develop later. Paleopathology ‘Though not really rare, archaeological examples of amputa tion are not abundant. The oldest case is that of a 46 000 year old Neanderthal from northern Iraq who had lost his arm. His finders postulated Neolithic surgical amputation but Majno (1975) notes that... there were surely more lions than surgeons in the immediate neighborhood..." Punitive hand amputation is recorded in the Hammurabi Codex of about 1800 B.C. Shortened, fused distal radius and ulna of a 45 year old male in Israel dating to the Middle Bronze period 3600 years ago testify to a right hand and wrist amputation (Bloom ea., 1995).A Ptolemaic Egyptian mummy revealed amputation of a hand with a prosthesis in place that was probably added by the embalmers (Gray, 1966). Another example of possible hand amputation in an adult mae from linois was reported by Morse (1978); this skeleton dermon- strated fasion of the distal ends of the radius and ulna. A ‘young pre-Columbian Peruvian ferale body showed 2 well- healed amputation of a humerus (Rogers, 1985). Other reports include possible cases from medieval Denmark, sev enth century Britain, Peru's Mochiea period, ninth dynasty Tgypt, Guatemala (900 AD. Maya), pre-Columbian Mexico and early historic Hawat Amputation: the soft tissue (finger) evidence Both rupestrian cave art and modem ethnological studies throughout the world document the practice of amputation of human fingers. Reports of such practices during the 1930s indicate that the practice of amputation of fingers dif fused to Africa from India or Indonesia, and was initially ‘employed by Hottentot widows who buried their amputated digit in their deceased husband!’ grave to pacify evi spirits Later it was extended to other threatening situations inelud- ing serious illness of other family members. In focal areas especially, cultural evolution resulted in its incorporation into the judicial system as a form of punishment in some tribes. The Kyiga of eastern Central Africa amputated a van- quished foe's digit as a war trophy and with the expectation that its possession would frustrate revenge efforts. South Africa's Herero people also amputated fingers of enslaved ‘war captives to publicize their servant status (Lagercranc2, 1935), Slmilar circumstances are described in Australia and ‘Oceania (S6derstrém, 1938)‘Undoubtedly the most commonly studied examples from. antiquity are those ofthe Gargas cave on the western slopes ‘of Mt. Gouret in southern France and from Tiberan cave on its eastern side. Together they display 143 handprints on the ‘ave wall, of which many demonstrate either missing parts of digits or actually entire digits. OF these, 130 are left hhands, suggesting that most ancient individuals were proba- bly right handed. Numerous caves in the region have rupes- twian handprints, but only those on Mt Gouret show ‘mutilation changes, Janssens (1957) points out they include ‘examples of direct imprints by a painted hand (‘positive print) a5 well as stenciled forms (‘negative’ print). Because the remainder of the hand is not distorted he also believes these are true amputations, not code messages formed by flexing various fingers. For various reasons he rejects a vari- ety of natural diseases (atherosclerotic gangrene, frostbite, osteomyelitis, syphilis, eprosy ete) as an explanation, bat is, puzzled wihy nearby caves do not reveal the amputations if Indeed, they were of ritual origin. Janssens cites Castaret (2951) as suggesting finger amputations were a form of sacrifice, giving examples from other cultures including Dygmies (sign of mourning), Hottentots (avert serious ill- ness), Mandan Indians of North America (consecration rites), Pacific Island natives (illness or death) and Berula Kodo, India (ritual. Janssens states thatthe purpose of these amputations must be resolved in medical terms, yet he does not appear to ‘embrace any of the possible diseases he considers. Given, however, the evidence of modern ethnology, it appears to the authors ofthis volume that the significance of this practice is rooted in supernatural ritual with predictable cultura evolu tion into punitive practices in focal areas. We have been tunable to identify reports of this lesion in archaeological ‘human remains. ‘While there appear to be few examples of amputated dig- its alone in descriptions of archaeological remains, ampu- tated feet and hands in a context suggestive of ritual have been identified quite frequently (Vreeland, 1978; Verano, 1986; Alva & Donnan, 1993). Trephination (trepanation) Definit ‘Trephination involves the production of a defect in the skull vault 0 create communication between the cranial cavity and the environment, whose success depends upon avoid ance of injury to the meninges, brain and blood vessels. History ‘Examining a pre-Columbian Peruvian skull sent him by the diplomat E.G. Squier, the French physician Pierre Paul Broca electrified the scientific community in 1867 by announcing SKELETAL EVIDENCE OF TRAUMA | 32 the defect was the product of prehistoric surgery and that the ‘patient’ had survived the operation. This was, however, not the first reported example, In 1839 Morton had described such a skull from Pachacamac, Peru but had misdiagnosed it as accidental trauma, Another was published 4 years later from Hungary by Kovacs (in 1843). In retrospect, Wells (4964) fele that a report of a skull in 1685 from Cocherel, France was the earliest example, though its true nature was not recognized until 200 years later. The fascination with these lesions has not ceased; Majno (1975) comments dryly that the number of publications (thousands) now probably, exceed the number of specimens found. Geographical distribution It is interesting that a procedure, seeming so exotic to us, should have such a large distribution in both time and space (Comas, 1972). In Europe and North Aftieatrephination can be traced to the Mesolithic in Poland, Russia, Taforalt and ‘Morocco and was practiced in these and other areas through- ‘out the Neolithic. In fact, Prioreschi (1991) estimates that between 6 and 10% of excavated Neolithic skulls have been ‘wephined. Excavation of post-Neolithic sites show far fewer examples, perhaps because of the popularity of cremation luring the later Bronze Age and La Tene period (Lisowski 1967). Hippocratic authors (400 BC.) noted its use for cer- tain cranial wounds and the Roman Celsus (ca. AD. 25) described it in detail. However the practice declined in Burope after the expansion of Iam and disappeared during the medieval period (Germana & Fornaciari, 1992: 164), Nevertheless, in spite of its broad distribution, it was far from a universal practice at any time. Within a broad area, ttephination seemed to lourish among certain groups. While nearly every Buropean country has revealed some trephined skulls Piggott, 1940), few have produced the large mumber excavated fom sites in southern France (Dastugue, 1973). Berbers and Kabyles from northern Africa practiced tephina- tion, as di the Guanches inthe Canary Islands, the Kisi from Kenya, Tende from Tanganyika, and the Masa A few such skulls have been found in Egypt Shaaban, 1984; Pehl, 1987). Jn Oceania Polynesian islanders as well as. those from Bismarck, New Britain, New Ireland, Tahiti and others also indulged in this activity but in Melanesia it was especially popular (Crump, 1901). In the New World a few specimens hhave been found in North America (Stone & Miles, 1990), ‘but pethaps the highest concentration of such skulls has bbeen found in the Andean area of South America, especially Peru and Bolivia between the fifth century B.C. to the fifth century AD (Bandelie, 1904; Grafia eal, 1954; Lastres & Cabieses, 1960; Allon & Pezzi, 1976). Such skulls have also been identified in Asia (Middle East, India, China, Japan, Pakistan, Afghanistan and southern Siberia.) Speculations regarding its spread by cultural diffusion have been difficult to support and currently popular scientific opinion views its distribution asa product of independent invention,32 Purpose earlier Iterarure reflecs intense controversy whose views ranged from magleal (release of disease spirit) 10 medical (herapeutics) (Courville, 1967; Margetts, 1967;Ackerknecht, 1971), Lisowski (1967) grouped the various suggestions nto three views: therapeutic, magico-therapeutic and ‘magico-ritual. Many Peruvian skulls demonstrate an intimate relationship of skull fracture lines with the trephine opening (Zimmerman etal,, 1981), which is cited as support for the ‘medical therapeutic view The magico-therapeutic concept views trephination as an attempt to release (expel?) an evil spiris causing any of a variety of different diseases originat- dng in the head such as headache, vertigo, neuralgia, coma, delirium, meningitis, convulsions and others, even includ- ing prophylaxis (Lisowski, 1967). An example could be that of a wephined young male from the Judean desert reported by Zias &e Pomeranz (1992) whose skull demonstrated three successive trephines that the authors feel were related to the onset and subsequent spread of suppurative sinusitis. A recent suggestion by Prioreschi (1991) may be a good example for support of the magico-ritual view.Tis author ‘postulates that an unconscious individual was viewed as dead and his recovery (either spontaneous or assisted by Fi. 3.14 Tepantion. Dred defet penetrates into ntl sinus and cana cavity. ( Closeup shows evicence of healing. (9 Scaping ‘mathe, Cas 7. Bronze age. Valencia, Span. Courtesy OD, Campi. Museu de Banyeres Fe, 3.13 Trepanation methods Four repanation techniques recansiruced| ‘om Priva shu (ee Auféerhlde 9) Drawings by Mak Summers reproduced hereby permission of Minnesota Mecsome procedure) considered as reviviflcation (rendered ‘undead’), Having established that recovery from the “dead! state was possible, rephination may have become one of the procedures employed to bring it about. Prloreschi cites many features of trephination consistent with this interpretation, For example, unhealed trephinations could be examples of the procedure carried out on already dead persons, and incomplete trephinations may represent recovery during the procedure. To these we could add the observation that the ‘many Neolithic examples ffom southern France that reveal no fracture or other pathology would also be consistent with such a magico-ritual view. In brief, all of these could have bbeen operative among different groups in different places at dlifferent times, Methods At least four, distinguishable methods (Fig. 3.13) have been observed, including (Aufderheide, 1985; Brothwell, 1994) 1, Grooving: A pointed instrument inseribes a round or oval _groove; repetitive tracing ofthis groove with pressure applied to the instrument eventually penetrates the skull, ‘The wound edge is vertical or steeply beveled. 2, Seraping: A sharp-edged, oval stone is repeatedly scraped ‘over a chosen area until the center penetrates the skull ‘The wound edges have a broad, shallow bevel. This is the ‘most popular type used in Peru, 3. The same tool as in (2) above is used by applying the edge perpendicular tothe skull surface while rocking and drawing ic to and fro until a linear groove penetrates the skull Three more grooves are produced to shape trectan- gle followed by removal ofthe circumscribed bone. Few of this type shaw evidence of healing ‘Acdecle of small holes are drilled through the skull, the bridges broken and the enclosed bone removed. Except for a few examples from Bgypt, Palestine and France, this method was limited to Pert, ‘Anatomical distribution Most trephine defects are in the left frontal (Fig. 3.14) and parietal bones (right-handed surgeons? right-handed assallante?). The occipital bone was rarely employed, Although the literature suggests most trephiners avoided the cranial sutures (and their underlying venous sinuses), out standing exceptions have been noted (Rodriguez. Mafflote, 1974a)..A Neolithic skull from Sweden has a healed trephi- nation in the middle of the sagital suture (Persson, 1976-77).A Canary Island aboriginal skull study found half Of the holes positioned on cranial sutures, most commonly the sagital and coronal, and 80% of these demonstrated healing changes Most skulls have only a single trephine defect, 2 modest ‘number have multiple openings and one Peruvian skull actu- ally demonstrates seven separate defects, ‘SKELETAL EVIDENCE OF TRAUMA | 33, Pathology Complete trephines are hose penetrating the fll thickness of both tables and intervening diploe. Incomplete trephines extend a variable distance into the skull bone but do not pen- cate the inner table. The latter have been viewed as a sym: bolic gesture (Dasrugue & Gervais, 1992). Complete healing is characterized by closed, smooth-surficed diploe but new ‘bone formation is only rarely sufficiently abundant to close the trephine defect (Fig. 3.15). A finely granular area of ‘osteitis surrounding the defect may indicate periosteal relec- tion while a more irregular, thickened surface characterizes a ‘complication of osteomyelids. Campillo (19914) carried out ‘experimental studies of trephination and cauterization in rabbits and concluded that the bone reaction to these two procedures was so similar that they were not useful for etio- logical predictions. The reactions were also less intense if not infected and necrotic bone sequestration and hyperostotic reactions were more marked when no sutures were applied. ‘Survival Surprisingly high frequency of rephination survival is apparent in all groups studied, as are the few complications Of osteomyelitis, Of 2000 crephined skulls examined by Fie. 225Tapanation, healing. Modem sll shows heslingwithaut templet obiteration of defects yearsafe surgical repine or daning bilateral subdural hemtome. BM,234 | TRAUMaric CONDITIONS Stewart (19580) half revealed long-term survival (ig. 3.14) and an additional 16% had partial healing changes. Bennike (1985) also found an 80% survival while modern operators {in Kenya claim a mortality of less than 5% (Aufderheide, 1985). Factors contributing to such success include the high vascularity of the overlying soft tissues (contributing to minimizing infection), and probable relative cleanliness of the instruments (perhaps lithies created at time of use: England, 1962). Several studies based on radiological changes found similar results. Guiard (1930) noted that earliest healing changes were detectable in about 2 weeks while a dense halo of sclerotic, reactive bone around the defect was found in those with longer survival of several ‘months and a wide zone of rarefaction was associated with, survivals greater than 1 year Similar changes using sernimi- roradiography were found by Lacroix (1972). These were found to correlate with expected macroscopic observations, (Ormer & Putschar, 1985). ‘A east some of the skulls lacking healing may have been trephined postmortem ~ perhaps to acquire a rondelle (2 round bone disc cut from the edge of a trephine defect with, a central hole for purposes of suspension), persisting, ‘moder Aftican practice (Merbs, 1989) or for purposes of practice surgery on cadavers. Since we can not be certain of the perimortem time of tephination, nor its purpose, Das- tugue & Gervais (1992) suggest avoidance of the term trephination and suggest use of an alternative: découpage postmortem (postmortem cranial incision) (Fig 3.16) Differential diagnosis Steinbock (1976) suggests thatthe following conditions ean simulate trephination: 1. Bolarged parietal foramina (‘Catlin mark’) — oval and symmenical 2. Cranial dysraphism (sharply defined borders). 3. Tangential sword cuts (inner table defect size exceeds outer). 4. Comminuted fractures (much more iregular) 5. Meaastatic carcinoma; myeloma (iregular, often multiple). 6. Bone neoplastas (benign can be similar; trauma, trephination and cauterzation produce synostosis; ‘benign tumors do not: Campilo,1991b) 7. Infections (syphilis, tuberculosis, mycoses: regular ~ Campillo, 1977) 8. Nonspecific infections (new bone response) 9, Parietal bone osteopenia (the skull depression is not sharply demarcated: Lisowski, 1967) 10, Postmortem alterations (stone abrasion, acd soils, animal effects). 11, Bxcavation injuries. In addition, Steinbock (1976) notes that, 2 group practiced trephination a all, usually a significant faction of the popula tion can be expected to demonstrate the lesion. Hence, aution Fe 226. Tepanaton, posthumous. Mule ied defects of infant skal ‘made postmorter (tual). Case 6 stheentuy&C Tlyotccuture, Matera, Span. Courtesy OrD. Campi UB. in making the diagnosis of trephination seems advisable if only am occasional sill in an archaeological population demon- strates the defect. Cranial deformation Intentional deformation of the cranium has a surprising antiquity Skulls estimated to be 45 000 years old revealing ‘evidence ofthis practice have been found among Neanderthal remains in Shanidar cave; in che Andean are it can be traced back nearly 10 000 years. The Hippocratie corpus deseribes the practice among Crimean residents. Ancient Mayan {iconography depicsit clearly While few Egyptian skulls have been shown unequivocally to have been deformed deiber- ately, Egyptian sculptors have portrayed the “heretic” pharaoh ‘Akhenaten and his children with deformed heads (though this may be symbolic-portraiture license to emphasize his special status) (Snorrason, 1946). Indeed, evidence from the ‘major populations throughout the world suggest a global dis- tribution ofthis practice in antiquity (Weiss, 1958), ‘The purpose(s) of cranial deformation probably varied {in time and space. Spanish chroniclers suggest that it served sa tribal marker in the New World’ Andean area (Garclaso de la Vege, [1609] 1966:485-6). Crete’s Minoans used the practice as a mark of distinction for their elite members (Gnorrason, 1946). Identification appears to be its most apparent function. However, the fact that Andean groups near sacred mountains deformed their heads in a manner con- forming to these mountain peaks suggest a possible religious cor ritual role as wel From a pathophysiological point of view, Moss (1958) pints out that the cloth deformer used to ereate the defor- i‘mation is not, by itself, responsible for the growth stimulus, nor is the bone the immediate agent of deformation. presently unidentified force drives and directs neural growth. When the deformer prevents lls growth in a certain direction, the orientation of cerebral ussue growth is deflected. The skall growth then follows growth ofthe brain ‘The forces may be directed by the dura mater which is attached to the skull during the growth period at five fixed points. These guiding principles result in two important effects: the final volume of cerebral tissue is not different from normal, and the deformed skull does not compress or impair cerebral tissue, Bjérk & BjSrk (1964) also note that placement of the deformer is not always perfectly central, swith the resule that one side may be deformed more than another. Distribution of growth forces, however, s such that appropriate compensatory shortening of the mandible and cranial base occurs so that dental fimction is not impaized, Cranial deformers and their use Pressure is applied to the growing cranium by a cloth band cr cord encircling the head, designed in such a way that its tension may be adjusted daily: Localization of the force is achieved by placing a substance between the scalp and the cloth band over the area of desired pressure focus, That sub- stance may be rigid ~ commonly a board — if complete flat tening of the area is desired, Substitution of a cloth or fur pad instead of a board results in a rounded effect (Pig. 3.17) Some of the deformers may have an additional band from ‘occiput to the frontal area over the vertex. The usual points selected for compression are the occiput or the frontal bone. Allison «al. (19814) have described a variety of deformers used in the Andean area, one of which contained a fice mask swith firm pads positioned over the malar bones. Weiss (1958) describes and illus- trates one in which the infant is lashed to palette, the deformer being stabilized by cords attached to a wood slat arching over the head. These deformers are applied soon after birth and are kept in place con tinvally, usually removed during the third year. Growth thereafter will continue in the manner directed by the deformer dur- ing infancy. Although older children and ‘occasionally even adults of the Andean area have been buried with a deformer in Position, these may well have symbolic significance in those age groups. The effects of these deformers have produced a bewildering array of cranial shapes. Hfforts to classify these has resulted in a variety of taxonomies rang. ing from 2 (Hrdlicka, 1912; Moss, 1958) to 15 different groups (Allison &t a., 19814). While Moss’ classification was shape Thanala-eated cultural group about AD. Boo-gooftom norte Chile's coast. HAUT. PBL “SKELETAL EVIDENCE OF TRAUMA |. 35, based on the relationship of the plane of the occiput to the Frankfurt plane as viewed on radiography, those of most oth- ers use features of lateral cranial silhouette. The two princi- pal influencing factors are the placement of occipital and/or frontal pressure substances and the nature of these sub- stances (hard or soft textured). The absence of both of these pressure-localizing devices results in a uniform, tall, cylin drical deformation. Almost infinite variations can be induced by application of differing degrees of tension and by varying ‘exact placement of the band as well asthe size and location of the pressure-localizing structures, For example, excessive tension on the band may produce sufficient overlap of cra- nlal bones so as to result in ridges and grooves in the later sutures (Fig 3.18). In fact, based on the appearance of the Fie 3.17 Cranial dtormer Camel ide covered vegetal cord enceled head and hed bal of cordage over aciput- Mas, TU2. MALT. PL, F218 ltentona cranial deformation Placement and tension of defer determined sal36 | TRAUMATIC CONDITIONS deformed cranium, archaeological efforts to recreate the structure of 2 missing deformer may mistake such a groove (produced in this manner by a simple circular band) a5 hav- ing been caused by an additional band over the vertex. Facial fattening is probably produced only by deformers that include & face mask with compression structures over the ‘malar bones, Intentional cranial deformation may produce some additional minor effects. Increase in the number of ‘wormian bones of the lambdoid sutures has been noted, but production of auditory canal exostoses, decreased cranial capacity or metopic sutures could not be confirmed in a aajor study of Andean skulls (Gerszten, 1993) It is surprising that the brain, distorted by a deformer, usually functions satisfactorily, inspite of the almost aston- ishing degree of shape alterations that are sometimes achieved. This is probably most easily understood by refer- ence to the previously noted observation that the growth of the brain is dominant and that of the skull will adapt and conform to it, avoiding compression. There are, however, “observations that suggest the outcome is not always benign. Excessive zeal in tension adjustment may cause the occipital pad or board to exert sufficient pressure to produce necrosis ‘of the underiying bone. More serious are occasional disasters resulting from the effects of such tension on the cranial sutures. Both the closure time and the chronological sequence of these sutures can be altered. The lambdoid usu- ally closes before the coronal in deformed crania, opposite the normal sequence, More serious is premature closure. If deformer deflects cerebral growth upward, few problems seem to occur as Jong as the vault sutures remain open. Excessive tension, however, can result in sufficient periosteal response in the affected suture to produce synostosis. With- out opportunity to expand in either direction the resulting constriction of the brain may be fatal. Guillen (1992:164) hhas noted several examples of this in the Andean area. The reactive change atthe suture may also generate a change so similar to porotic hyperostoss that it can only be differenti- ated from it by its distribution pattern: « band of spongy- appearing bone 11.5 cm wide, sharply demarcated, located immediately adjacent to the affected suture (Aufderheide, 1990; Guillen, 1992:156) Cauterization “Thermal injury tothe sealp issues and the skull’ outer table has been employed since Neolithic times until the Medieval period. The speculated purposes are similar to those ‘expressed for ephinatlon as discussed above. The methods of heat application varied widely and included cauterizing the sealp with smoldering ashes (Kiwakiud Indians of Canada); holding glowing ember (Yakuts) oF burning wick (Central Canadian Inuit or Eskimos) or burning piece of ‘wood (Osage Indians) or ed hot stone or animal fit (Canary Island Guanches) on the sealp atthe site of pain Sincipital T cauterization ‘This unique form of cauterization involved using heat, in cone ofthe above or similar forms, applied in a linear (ante- ror to posterior) streak usually inthe skul’s midline, often (but not invariably) terminating in a shorter line at right angles to effect a T-shaped lesion. Sufficient necrosis of soft tissues and the skull’ outer table is achieved to produce a permanent, depressed groove in the skull chat does not pene- trate the inner table. The lesion was first described in six female Neolithic skulls from southern France. Wells (1964) suggests the sealp may have been incised and boiling oll ‘poured into the incision. In the Canarian Guanches the cau- terized area is oval instead of linear. Loss of blood supply causes ischemic necrosis with bone dissolution and sur- rounding sclerotic response. The changes reach the level of the dura only rarely The fact that most subjects are females, and children suggests a ritual significance. Geographical distribution Wide distribution of such lesions have included the New World (Peru), Europe (France, Hungary, Czechoslovakia). Canary Islands (probably notas Frequent as the 10% reported by Luschan, 18960,8), Africa and central Asia, The numbers of cases, however, are far fewer than for trephination. Differential diagnosis (Osteomyelitis can simulate this lesion. Indeed, in his expert- ‘mental studies on rabbits Campillo (1977) pointed out that the skeletal response to both osteomyelitis and cauterization ‘were qualitatively indstinguishable and were not dependent ‘on the cause but rather on the degree of subsequent inflam ‘mation, The lesion has been confused with treponematosis and Weiss (1958) suggests using the remainder ofthe skele- ton to exclude this infection, Occasionally senile atrophy ‘may produce sufficient osteopenla to mimic this lesion (Ormer & Putschar, 1985). Bloodletting ‘The deliberate induction of blood los isan almost universal practice among nontechnological societies (Ackerkneckt, 1971), Ithas been applied for almost every conceivable con- dition for which no other effective therapy was available It reached the peak of its popularity in the nineteenth century: in 1883, 40 million leeches were imported into France for this purpose. “Methods varied from scarifiation (multiple small inci- sions of the skin co induce controlled bleeding) to cupping (application of a horn with negative pressure to sarified areas) to vensseetion (incision into 2 vein ~ popular in ‘America, Oceania and parts of Africa) and finally to leeching j j | | pei. 3.49 Selping. erimartam ut marks ecler (a) nega raw bone on cuter adie) cue to osteomyelitis ndicatigpostscalping survival. Late precantact uper midwestern Nort rerican aboriginal Courtesy Dr lon Greg and USDAL, Phtoarephby Glenn Malchow, ( the application of blood-sucking water animals tothe skin for wound). The latter was rarely employed by prehistoric societies (Ackerknecht, 1971) Scalping Definition and Pathology Scalping represents the excision of 2 variably-sized segment (of scalp. While this can occur accidentally in antiquity it was almost invariably carried out for the purpose of acquisition of a human ophy. While Hamperl & Laughlin (1959) describe the removal of the scalp with underlying perios teum, it is unlikely that areas of periosteum of significant size were removed very often because of its dense adherence to the bone and the urgency ofthe battle conditions that fre quently prevailed. Nadeau (1944) describes the North American Indian scalping process as varying from removal of all or only part of the scalp from usually a single (occa sionally multiple) area that sometimes permitted the poste- rior part of the avulsed scalp to hang down on a pedicle. Use of a metal knife frequently did not injure the skull bones but the irregular edges of lithic knives often incised the perios- eum and underlying outer table (Hamper! & Laughlin, 1959; Steinbok, 1976), SKELETALEVIDENCE OF TRAUMA | 37 While scalping was accompanied by substantial hemor- ‘age from the rich vascularization ofthe scalp, when death cocurred it was usually due o other lethal wounds, in their absence, recovery was not uncommon. In these the bone Changes were a response to the incisions and the skeletal Ischemia secondary to deprivation of the sap’ blood sup- ply with bone necrosis of the outer table, and granulation tissue separating the necrotic area from the deeper, suviv ing bone. New bone formation was common, resulting ia a final appearance ofa depressed and eventually smooth zone that ean be uneven over a broad area. Moderate porosity at the margins reflects increased vascularity and inflamma tion. Farther irregularities were superimposed by he changes induced by osteomyelitis when infection occured (ig 3.19) Geographical distribution Although native North American scalping practices are the ‘most well-known, it must be noted that similar procedures were practiced by ancient Scythians, Palestinés, Maccabees, a5 well as the Anglo-saxons, Visigoths and Franks until the ninth century A.D. Furthermore, although the practice was employed by North American aboriginals before the arrival of Europeans, it was greatly encouraged by the English, French and American governments.38 | TeAumaric conormions Paleopathology ‘The paleopathologicl literature of the US.A, records mumer- cous examples of scalping including male Arkara Indians from South Dakota, adult males from the Missssipian period in ‘Arkansas, the mile Missisipian period in Minos, three pre- historic and early historic skulls from Virginia, an adult female from Alabama, 2 prehistoric skull from Nebraska and many others. Ortner & Putschar (1985) describe an interesting example of a pre-Columbian adult female skull from Georgia (US.A.) with an irregular surface area on the frontal and both parietal bones without evidence of active inflammation sug- gesting the formation of granulation tissue without infection Cover this entire area and with good, complete recovery. Allen eal. (1985) introduced a unique suggestion that grew out of examination of 10 Hopt Indian (Arizona) skulls ‘with healed, depressed fractures, severe infection and lunhealed injures. In all of these the stigmata of scalping ‘were superimposed. They suggest the purpose of the scalp- ing incisions was to expose the underlying pathology in order to gain experience with the appearance of the tissues alleceed by these conditions —a primitive type of autopsy. Crucifixion Crucifixion was one of several methods of execution for ‘major crimes such as reason during the Persian and Roman, pperiods of Egyptian history. A variety of crucifixion forms ‘was employed including the traditional + forms (with over- lapping feet) as well as the X form (with legs spread. In some Instances the body was tle to the cross, while in others it was nailed there. Tradition suggests that nailing of the + form involved a single nail through overlapping ankles (Lewis, 1995) (Fig 3.20). Barbet (1953), experimenting with freshly amputated arms, concluded that suspension from. hands nailed through the palms would not tolerate the body ‘weight and these would need, in addition to the nails, to be ‘bound to the cross with a rope. Later experiments suggested that a nail driven through the hand at the posterior end of the first and second metacarpal would, indeed support the cruci- fied body (Zubigwe, 1982:65-7). Alternatively, nail suspen sion without binding would be adequate if the nail were placed between the distal radius and ulna, Further anatomic ‘evidence of crucifixion would be apparent through the prac- tice of crurifagium (deliberate fracture ofthe long bones of the lower extremities and sometimes the upper as well. ‘Zubigwe (1982:92), however, challenges the idea that this hhastens death by causing the body to slump and impair respi- ration; he believes it probably induced death by shock, ‘because his experiments with living volunteers demonstrated that respiration was impaired only if the hands were fled above the head and not if they were spread asin erucifixion Crucifixion by rope suspension alone would inflict only nonspecific soft tissue lesions, while those employing nails ‘would involve skeletal evidence, Unless nails were located precisely behind the first two metacarpals, hand mailing would abrade, traverse or shatter metacarpals while ankle nalings could be expected to involve lar bones, especially the talus and caleaneus, Furthermore, fractured long bones dn the proper context can alert the examiner to this possibil ity, especially when crurffagium also involved the arms, suggesting a deaied search for crucifixion lesions (Redford & Lang, 1996), ‘Because of differing crucifixion practices (Seneca, cited in Lewis, 1995, even states some were crucified upside down), paleopithologists can expect nails to have been placed in dhe hands, wrists, ankles and feet (both individu- ally and overlapping) Paleopathology Considering the number of erucifitions that were probably carried out, the archaeological evidence contains few exam- pes accompanied by convincing anatomic lesions. One is that ‘ofa young adult male from a Jerusalem burial cave (Giv’at ha \Mitvar:Teafers, 1985) in which the right calcaneus was trans- fixed by an 11.5 x 1 cm nail still in positon, andthe tibia and fAbula were fractured without evidence of healing (Haas, 1970; Zia & Sekeles, 1985) The other is from Mendes harbor in the Nile deta believed to be from about A.D. 0 + 100 years ‘Two adult males showed the long bone fractures characteristic of crurifragium, In addition, one of these revealed a nail hole ‘through the distal right femur and also a mil hole suggesting the left foot overlapped the right foot atthe ankle. A nal hole traversed the lft ankle, the left heel andthe medial side ofthe right heel (Redford & Lang, 1996; Patrick Horne, personal communication). Lewis (1995) suspects crucifixion evidence is being overlooked often by osteologists because the crucifix- ion mails, highly valued for their reputed medical therapeutic potential, were commonly salvaged afer death ‘SOFT TISSUE INJURIES: INFLICTED BY OTHERS Lacerations and stab wounds: Antemortem or postmortem? The frst decision an examining paleopathologist must make 4s the determination whether the observed injury was inflicted before or after death. Unfortunately few reliable ce- teria ae applicable o assist in the solution ofthis question even in fresh tissue, and even fewer in mummies. Of these, the most useful is hemorrhagic exudation into the wound ceiges, adjacent tissue or body cavity. Old hemoglobin is usu- ally black. When present in abundance, enough molecules,Fie, 3.20. Crean. (0) Mader al demonstrates calaneus defect. (0) curtragu evidence (deters long bane Fracture). Adu male, ‘often retain thelr chemical composition sufficiently to react positively with commonly employed identifying chemical tests, Red blood cell preservation is rare in mummies. I the individual survived the wound for at least several days, heal- {ng changes of the wound itself (gradual rounding of the ‘originally sharply-defined wound edge) wall be valuable evi- dence of the wound’s anternortem nature. Much less reliably, the presence of artifacts (bandages, splints, etc) relating to the apparent wound can suggest antemortem context. In addition, the paleopathologist must be alert ro the possibility of a given defect heimg the consequence of spontaneous, postmortem changes (pseudopathology). The skin of bodies ‘undergoing natural postmortem desiccation may become very britdle and rigid, particularly when underlying soft tis- sues have decayed and no longer support the dry, overlying skin, Soil pressure or even ordinary handling of the body during excavation may then split the skin in a manner sug- gestive of antemortem wounds, Indeed, itis our experience that far more than half of skin defects examined prove to be products of such a taphonomic process If the lesion is an isolated one and the paleopathologist is satisfed that it is not 2 pseudopathologic phenomenon, yet cannot identify evidence ofits antemortem nature, the use of| the cerm ‘perimortem’ may be preferable. This adjective implies the lesion was inflicted near the time of death, but SOFT TISSUE INJURIES: INFLICTED BY OTHERS | 39 ied ce.A0. 0, Courtesy atl Lang and keaton Temple rie, oa Ontario Museu, Toronto could have occurred immediately before or very soon after death. On the other hand, the presence of other, clearly ante- ‘mortem injuries can be useful in judging an otherwise ques tionable lesion. Thus, the context within which the lesion is found can supply atleast circumstantial evidence of is origin. Figure 3.21 is an example of such a quandary-The body is that of a spontaneously desiccated adult male from a dif dwelling in southwestern US.A..The right side of the ante- rior abdominal wall revealed a vertically-oriented defect 11.5 em long At its upper end the skin, muscle and peri- oneum-fascia layers were all penetrated simultaneously by the cutting instrument as indicated by the fact that each layer ‘was evident in the sharply-defined wound edges. The lower (istal) end of the wound, however, revealed all thre layers arranged in a stepwise fashion, the skin being retracted the ‘most, the muscle next and the peritoneum-fascia layer still intact beneath the muscle for a distance of several centime- ters, This is precisely what would be expected if a cutting blade had stabbed the anterior abdominal wall in the right ‘upper quadrant, and had then been forced downward (dis tally) to create the defect. However, after reaching the right lower quadrant the blade’s downward course was apparently continued a¢ the same time the blade was withdrawn, Thus, it left several centimeters of peritoneum and fascia intact, while continuing to lacerate the muscle layer, Further