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Paleopathology INTRODUCTION Paleopathology, the study of disease in ancient remains, is aimed at improving our understanding of the evolution of diseases and their interaction with human biologic and social history (Aufderheide & Rodriguez-Martin, 1998; Brothwell & Sandison, 1967; Ortner & Aufderheide, 1991). Pathogenic organisms, environmental factors, and patterns of disease evolve just as do larger organisms, including hosts and vectors of disease. There is evidence, however, for considerable stability in some hostparasite relationships. Similar parasitic worms have been found in Egyptian mummies and modern Egyptians. Such historical perspectives are necessary to prepare us for changes in disease incidence and for new diseases, such as Legionnaires disease and AIDS (Zimmerman, 2001). Evidence of ancient disease is obtained from historic records, works of art such as paintings, pottery effigies, and figurines, religious statuary, figures and faces on coins, skeletons, and mummies. Many diseases leave little or no direct mark on the bones and pseudopathologic changes can be produced by erosive forces or animals chewing on bones. Although lesions in archeological specimens represent only a small proportion of the total morbidity, the incidence of disease of a population, there are valid reasons for such studies. Certain characteristics or anomalies are useful as genetic markers. Evidence of traumatic injuries can give information on the occupational or military orientation of the group under study. Infectious diseases provide inferences on the general health status of the population. A major consideration in dealing with ancient material is that modern patients with skeletal pathology present one with symptoms and signs, whereas archeological material presents one with a bone that has either a hole or a bump. The diagnosis of skeletal lesions is properly based on history, radiological findings, and pathology, but we rarely have adequate history in dealing with ancient skeletal material, and pathology is generally confined to the gross appearance, as microscopy is highly technical (Schultz, 2001). One other caution is the paradox that skeletons showing pathology are usually those of relatively healthy individuals. Unhealthy individuals die very quickly, before they have time to develop skeletal lesions. Mummies are bodies preserved either artificially or naturally. The Egyptian practice of artificial mummification developed from the natural preservation of bodies buried in the desert in preDynastic times, which may have had a role in the development of the belief in life after death. When it became customary to provide the deceased with food and funerary furniture, larger graves and aboveground tombs allowed decomposition, necessitating the development of artificial techniques of mummification. All deceased Egyptians were mummified until the Christian era, ca. 200400 AD, with a gradual refinement of technique over the millennia, although in all periods the poor were less carefully mummified (Zimmerman & Angel, 1986). Artificially preserved mummies are found in many other areas of the world as well. Natural mummies, due to freezing or drying, have been found in bogs and in arctic and arid areas. These bodies, both human and animal, often show excellent preservation (Spindler, Wilfing, Rastbichler, et al., 1996). The rehydrated tissues of mummies subjected to autopsy examination result in the diagnosis of many conditions with a considerable degree of confidence and accuracy (Cockburn & Cockburn, 1998). Mummified tissues and bones are studied by light and electron microscopy, chemical analyses, and paleoserology. Microbiological studies have not been useful, as viable pathogens have not been cultured from paleopathologic material, although organisms can be identified histologically, including viruses, using electron microscopy. THE HISTORY OF PALEOPATHOLOGY

After an early 19th-century period focusing on the examination of native American skulls, interest shifted to evidence of disease, dominated by activities at the Smithsonian Institution, the Army Medical Museum, and the Peabody Museum at Harvard. In Europe a controversy arose when Rudolf Virchow, the German pathologist, anthropologist, and politician questioned the authenticity of the Neander Valley specimen, suggesting that the Neanderthal remains were those of an abnormal modern man suffering from rickets or syphilis. The next period, from 1900 to 1970, began with the Smithsonian appointment of Ales Hrdlicka. Describing lesions that he called symmetrical osteoporosis, he noted that they were probably representative of a systemic disorder. He built one of the worlds great collections and contributed to the training of many anthropologists. Flinders Petrie examined prehistoric Egyptian bones by X-ray in 1897, but the technique was little used until the work of Roy Moodie in the 1930s, and is only now beginning to be fully utilized. The first of the truly modern paleopathologists was Sir Marc Armand Ruffer. Ruffer was an English experimental pathologist and bacteriologist of some note when an illness forced him to Egypt for recuperation. He developed the rehydration technique that is still in use for preparing microscopic sections of mummies and made a number of important diagnostic contributions before being lost at sea in World War I (Ruffer, 1921). The first full-length book on paleopathology was written by Roy L. Moodie (1923), an American anatomist. His book covers humans, lower vertebrates, plants, etc. and contains many errors, mostly related to the theories of the early 20th century. Moodie also edited Ruffers collected papers and published other books and papers in the field. Paleopathology was revitalized in the 1970s by the activities of three groups. The Paleopathology Association was founded in Detroit by Aidan and Eve Cockburn and 12 charter members. The association publishes a quarterly newsletter and has studied a number of mummies. These studies have gone far toward improving the difficulties that were experienced in interpreting lesions in the past, and a wide variety of new techniques have come into play. These include more sophisticated radiographic studies such as computed tomographic scanning, electron and scanning electron microscopy, fluorescent antibody and other serologic techniques, neutron activation analysis, and other chemical and microbiological techniques. A second group, headed by Marvin Allison and Enrique Gerszten at the Medical College of Virginia, Richmond, has conducted an extensive survey of Peruvian and Chilean mummies. A seminar in paleopathology was held at the Smithsonian Institution from 1971 to 1974. This fulllength course provided a continuing major impetus in paleopathology. As world-wide interest in the field increases, with much research being conducted in Europe, South America, and Australia, the number of journals accepting paleopathology articles also is increasing, as summarized by the Bibliography of Paleopathology published by the San Diego Museum of Man (Tyson, 1997). TECHNICAL CONSIDERATIONS The preservation of buried bone varies with soil type. Bones from acidic soil areas, such as Mesoamerica, will be softened and often in poor condition. Careful excavation of skeletons, with complete clearing of the soil, is essential. Most bones can be cleaned with warm water. Skulls should be examined first for remnants of brain tissue and for ear ossicles. Hot paraffin wax, formerly used for conservation of bone, can be damaging. Shellac preserves the surface but tends to peel off in a few years, taking bone with it. Soluble plastics are the best preservatives. Plaster of Paris is good for support but difficult to remove from bones (Brothwell, 1972). Examination of mummified remains depends on rehydration of the tissues. Ruffers rehydrating solution, still in use today, is 50 parts water, 30 parts absolute alcohol, and 20 parts 5% sodium carbonate

solution, most easily prepared by dissolving 0.6 gm of sodium carbonate in 42 ml of water and adding 18 ml of absolute (100%) alcohol. Allison simplified Ruffers technique by immersing the tissue in Ruffers solution until fully rehydrated to visual inspection (usually 2448 hr). The tissue is then fixed in alcohol and processed. If the tissues dissolve in the solution it is because they are completely contaminated by bacteria. The solution always develops a dark brown turbidity (Zimmerman & Kelley, 1982). A variety of special stains can be used to demonstrate specific features of the tissues. In general, connective tissues and any foreign elements, such as pigments, bacteria, or parasites are best preserved, while epithelial tissues fare less well. Thus the connective tissues stains are those used most. The standard hematoxylin and eosin is useful only in a very general sense. Other techniques that have been applied to rehydrated tissue include plastic embedding of bone specimens and scanning and transmission electron microscopy. Dating of biological materials, human or nonhuman, is often of importance in dating an archeological site, either independently or in correlation with conventional archeological techniques such as the evaluation of pottery, hieroglyphic texts or other artifacts, or historical records. In paleopathology, dating is essential in providing an historical context for the evaluation of disease processes detected. Radiocarbon dating is the gold standard, but a variety of other techniques are applicable. These include amino acid racemization, which is temperature dependent, electron spin resonance, and ancillary techniques such as dendrochronology, mummification styles, and tattoos (Zimmerman & Angel, 1986). Age determination is another important facet of the study of human remains, allowing the construction of population profiles and the development of a paleoepidemiologic approach. At the individual level, many diseases occur in specific age ranges and age determination can be a critical factor in differential diagnosis, particularly with regard to bone diseases. In contrast to dating, no single aging technique is best. Techniques used include gross evaluation of the skeleton and viscera, hand wrist radiographs, bone histology, dental changes and, in special cases, amino acid racemization (Zimmerman & Angel, 1986). THE CLASSIFICATION OF DISEASE Cells continuously adapt to internal and environmental stimuli and stresses. If the cell is no longer able to adapt, then cell injury results, either reversible or leading to cell death, necrosis. Injury that cannot be limited at the cellular level calls forth an inflammatory response. If the stimulus is terminated, then the acute reaction subsides and there is usually healing and regeneration of the tissue, although specialized tissue such as the brain is replaced by scar tissue. If stimulus and inflammation continue, then a chronic phase follows. Regeneration and repair are attempted, with scarring the almost inevitable result. Special types of inflammation include allergic inflammation, granulomatous inflammation (tuberculosis or foreign body reactions), ulceration (the loss of the lining or surface of an organ), and abscess formation (accumulation of pus in solid tissues). These cellular and tissue reactions to stresses and stimuli result in a wide variety of disease states, falling into the following broad categories: congenital defects, trauma, infectious disease, metabolic and nutritional disease, degenerative disease, immunologic disease, circulatory disorders, and neoplastic disease. PALEOPATHOLOGIC FINDINGS Congenital Defects These defects, which are present at birth, may be hereditary or acquired before birth. Many are minimal and do not cause any functional disability. There can be abnormal fusions of bones, or failure of bone components to fuse. Skull sutures may vary in their relationship. Statistical analysis of skeletal variations can reveal significant associations and inferences as to the

biological affinities of the individuals under study. Examples of acquired congenital disorders are infections such as German measles and syphilis, and chemically induced abnormalities such as the thalidomide babies born in the 1950s. Congenital dwarfism is a generalized condition that is easily recognized. Achrondoplasia, the most common form, is due to a hereditary defect in the formation of enchondral bone, that is bone formed first as cartilage. There is shortening of the bones of the extremities and the mandible and forehead appear prominent. The long bones are relatively thick and the head is larger than normal, with a prominent frontal region, small face, and depression of the bridge of the nose. The legs and spine are curved as well. This condition is of great antiquity and wide geographic distribution, with skeletal remains from the pre-Columbian New World and documentation in ancient Egypt from pre-Dynastic times up to the 30th Dynasty by skeletons, wall paintings in tombs, figurines, and statues. The ancient word for an achondroplastic dwarf was nemew and they held various offices, as these dwarves are generally of high intelligence. Very accurate depictions show them in charge of jewelry or pets or in personal attendance on their masters, often acting as jesters. Several of these dwarves must have been persons of considerable wealth and importance, being found in elaborate and costly tombs. There was also a magical significance, accounting for the figurines and amulets, associated with spells to facilitate birth. Other examples of congenital disease include: hydrocephaly from Roman Britain, Egypt, and Neolithic Germany; a case of Downs Syndrome in a 15th century AD Inuit child mummy from Greenland (Hart Hansen, 1998); alpha-lantitrypsin (AlAT) deficiency and emphysema in another Inuit child, from 10th century AD Alaska (Zimmerman, Jensen, & Sheehan, 2000); and spina bifida, a failure of closure of the sacrum, in Egyptian mummies. Traumatic Injury Fracture constitutes the most common bone pathology in both ancient and modern material (excluding arthritis). If there is adequate immobilization of the bone, then healing can be almost perfect, while poor immobilization can lead to imperfect healing or nonunion. However, many wild animals have well healed fractures. Medical intervention may not be as necessary as we think; a well healed fracture in an archeological specimen need not imply the presence of an ancient orthopedic surgeon. The recognition of traumatic injury in ancient material can be difficult. Fractures or wounds, such as sword cuts, if incurred shortly before death, will show no evidence of healing and may be impossible to differentiate from postmortem injury. If there has been time for healing, then rounding of the edges of wounds or callus in a fracture site will be seen. Although sprains and dislocations probably cannot be recognized in skeletons, both are mentioned extensively in the Egyptian medical papyri. Fractures have been noted in Peruvian, Alaskan, and Egyptian mummies. Some of the fractures are either postmortem or embalmer fractures, but there is radiological evidence of healing in some cases. Trauma appears to have been common throughout human evolution, and before humans as well, with fractures being seen in dinosaur skeletons. The history of human violence is certainly a long one and different weapons produce different types of injury. These have been divided into four classes: (1) large stones or clubs produce gross crushing, with a primary depressed area and radiating cracks; (2) smaller clubs, maces, and missiles produce less extensive fractures, often of the nose or long bones, which are likely to show signs of healing; (3) spears, arrows, and daggers produce well-defined piercing wounds and the weapon occasionally remains in the body; and (4) sword cuts produce long deep gashes. Examples of trauma and violence are seen in Neanderthal skeletons from Shanidar Cave in Iraq, dated to 47,00060,000 years BP. Four of six adult skeletons exhibit some form of traumarelated

abnormality and at least two of the individuals appear to have been severely debilitated by their injuries. Shanidar 1, the most severely debilitated, had suffered multiple fractures. A crushing fracture in the area of the left eye probably caused blindness. His right arm had suffered multiple fractures of the distal humerus, with amputation above the elbow, osteomyelitis of the clavicle, and a marked decrease in size of the remaining humerus, clavicle, and scapula. All of the fractures and injuries occurred years before his death, as indicated by extensive healing and resorption of callus. The most likely explanation is that he sustained a massive crushing injury to the right side of the body, perhaps in a rock fall in a cave, with loss of the distal right arm. The small size of the arm bones could be the result of hypoplasia if the injury occurred in childhood or atrophy due to associated nerve injury and disuse if the damage had been done in adulthood. Either interpretation is consistent with a prolonged period of survival. The right foot shows a well healed fracture, with osteoarthritis of the ankle and knee. Since the left foot, ankle, and knee appear normal, such asymmetry suggests disruption of normal function and abnormal locomotion. Shanidar 3 shows a penetrating wound involving the 8th and 9th left ribs, with survival for several weeks. The angle and position of the wound are what one would expect if a right-handed individual had stabbed Shanidar 3 in a face-to-face confrontation. If this interpretation is correct, then this is the oldest case of human interpersonal violence, although it could have been accidental. Whatever the circumstances, Shanidar 3 was clearly nursed for at least several weeks and intentionally buried. He also had severe osteoarthritis in his right ankle. This asymmetrical arthritis was probably related to a fracture or severe sprain. Shanidar 3 therefore suffered a locomotor disability and died a violent, although perhaps accidental, death. Every currently known and reasonably complete Neanderthal skeleton shows evidence of trauma, suggesting that life in this group was indeed harsh and dangerous. Evidence of healing and long life span implies that the Neanderthals had achieved a societal level in which disabled individuals were well cared for by other members of the group. Elderly Neanderthals such as Shanidar 1 and 3 must have contributed in an intellectual manner to the group well-being and it is not surprising that many of these individuals were intentionally buried (Trinkaus, 1983). Trauma was common in ancient Egypt. Parry fractures of the left ulna (due to raising the left arm to ward off a blow) are often seen in Egyptian skeletons. The Edwin Smith medical papyrus is primarily a surgical treatise with much emphasis on physical injuries. Fractures were treated by reduction and splinting and many well healed fractures have been seen, as well as examples of malunion and nonunion. Death due to aspiration of foreign material has been seen in two mummies. A Peruvian mummy of 950 AD was found to have aspirated a molar tooth, with pneumonia distal to the obstruction (Allison, Pezzia, Gerszten, Giffler, & Mendoza, 1974). An Inuit woman died 1,600 years ago of asphyxiation secondary to aspiration of moss when she was trapped in her house during an earthquake or landslide and buried under the moss roof (Zimmerman & Smith, 1975). Another example of trauma is the finding of a family in Barrow, Alaska, dated to ca. 1500 AD, all killed by an incursion of ice crushing their winter home. The bodies showed fractured ribs and fatal hemorrhage into the chest cavities; one of the bodies was found with a roof beam across her chest (Zimmerman & Aufderheide, 1984). Trephination (a type of surgical trauma), the removal of a piece of the skull without damaging the underlying vessels, meninges, or brain, is a wellknown and widespread phenomenon. The practice was world wide, beginning in Europe 10,000 years ago and in Egypt, where there are only a few examples, about 1200 BC. In South America the practice dates to about the 5th century BC. It may have been done for fracture or headache, or to let out evil spirits. In 20th-century Kenya it was most often done for headache. When done

postmortem, the piece of bone from the skull is used as a good luck charm. The procedure generally involved alcohol as an anesthetic and a variety of instruments to remove the pieces of bone, by drilling, scraping, or cutting. The majority of patients appear to have survived the procedure. The technique, still practiced in Africa until recently, is performed by some in the United States even today. One caution is that spontaneous diseases can cause similar appearing holes in the skull. Infectious Disease These disorders are caused by microorganisms, including bacteria, viruses, rickettsia, fungi, and single-celled protozoan parasites. Invasion by macroorganisms, those visible to the eye, such as worms and insects, constitutes infestation. Modern treatment has altered many diseases and comparison between ancient and modern diseases must keep this fact in mind. Most infections do not affect the skeleton directly, but the skeleton can be involved indirectly. Childhood infections can result in the production of growth arrest lines or Harris lines in the long bones, resulting in a very rough index of morbidity. Infections that result in anemia cause a secondary hyperplasia of the bone marrow, particularly in the skulls of children. X-rays show a characteristic hair-on-end appearance and the external surface of the bone shows osteoporotic pitting, called porotic hyperostosis. The geographic distribution of this lesion has been shown to overlap that of malaria and these conditions have been linked to sickle cell anemia and thallessemia. Bone infections, osteomyelitis, mostly bacterial infections, reach the bone by a penetrating injury such as a laceration or open fracture, by the bloodstream from a distant site, or by direct extension from an infection such as a soft tissue or dental abscess or a sinus infection. Mastoiditis has been found in Neanderthal, Nubian, Egyptian, and American Indian skulls, secondary to middle ear infection. The infected bone becomes necrotic and is surrounded by pus, which may drain to the surface through sinus tracts. Such infections can still be very difficult to treat and may persist for years. Pyogenic osteomyelitis is an ancient disease, having been described in dinosaur skeletons. An infection with extensive historical documentation is bubonic plague, caused by Yersinia pestis. The black death killed more than a quarter of the population of Europe in the 14th century. Infection is transmitted to humans by the bite of an infected rat flea. The lymph nodes become greatly swollen (bubos), or, under conditions of crowding, transmission is by inhalation, causing a rapidly fatal pneumonia. Sporadic infections still occur, traceable to wild rodents. A spirochetal disease of significance in human history is syphilis. Advanced acquired disease results in damage to many organs, including the cardiovascular system, skeleton, skin, and upper respiratory tract. Congenital syphilis is passed across the placenta and is characterized by deformities of the teeth, legs, and face. The periostitis of syphilis is quite distinctive, but in archeological material can be impossible to distinguish from yaws. The origin of syphilis, New World or Old, has long been a point of controversy. One school holds that the varying spirochetal diseases are different manifestations of the same disease in different populations. Some feel that yaws originated in the Pacific, spread to the New World and manifested itself as syphilis when contracted by adult European explorers, while others believe that syphilis was present in the pre-Columbian Old World. Tuberculosis, caused by an acid-fast bacillus, affects the bone in a certain percentage of cases with destruction of joints as well as bone. Involvement of the vertebral bodies causes collapse and hunchback (kyphosis or Potts disease). There are good examples from Dynastic Egypt, but not pre-Dynastic, suggesting a possible evolution from the bovine form of the disease, cattle having been domesticated at the beginning of the Dynastic period.

Tuberculosis has been found in Europe at about 2000 BC and in a mummy from pre-Columbian America, where pottery figurines with kyphosis are also found. Leprosy, caused by another acidfast bacillus, is a disease of considerable historical interest, because of Biblical references and the fact that the characteristic bone changes in the disease were first delineated in a study of medieval skeletons. The primary infection is through the nose, with atrophy of the maxilla in the region of the incisors, with or without loss of teeth, inflammation of the hard palate, and atrophy of the nasal spine, these lesions having been identified by Moller-Christiansen in medieval lepers. While leprosy is mentioned in the Old Testament, the earliest skeletal evidence dates only to early Christian era Europe. The disease was certainly common in Europe by medieval times, but most of the lepers were killed off by the bubonic plague. Although viruses are responsible for a long list of human diseases, there is little evidence of these intracellular parasites in paleopathology. A rare example is the mummy of the Pharaoh Siptah, of the 19th Dynasty, which shows a leg deformity characteristic of polio. Smallpox has been diagnosed in the mummy of Ramses V and a mummy of the 20th Dynasty. The effects of viruses on nonimmune populations have been demonstrated repeatedly. Measles, smallpox, and yellow fever have been largely responsible for the decimation of aboriginal populations in America, Australia, New Zealand, and among the Inuit. Fungi are plants that produce chronic infections in humans. These organisms are often seen in paleopathology but are invariably postmortem contaminants. Protozoa are single-celled animals responsible for many infections, primarily in tropical and underdeveloped countries. Evidence of the malaria has been found in Egyptian mummies. Diseases caused by helminths (worms) are relatively uncommon in temperate climates but have a major impact on tropical and subtropical areas. Worms are classified morphologically as roundworms (nematodes), flatworms, or tapeworms (cestodes) and flukes (trematodes). Most helminths have elaborate life cycles often requiring intermediate hosts and almost always involving the ingestion of infective forms, ova or larvae, by the definitive host. The effect on the host is variable. Some parasites cause profound debilitation while others have a more benign course. The latter probably are better adapted to their host, as it is to the advantage of the parasite for the host to be in relatively good health, death of the host meaning at the least a search for a new host, if not death for the parasite as well. The effects of the parasite on the host may bear a roughly inverse relationship to the time that the two genera have been associated. Parasitic worms and their ova remain well preserved for millennia, and the characteristic ova of a roundworm, Ascaris lumbricoides, tapeworm, Taenia solium, and blood fluke, Schistosoma hematobium, have been reported in Egyptian mummies, including one case of death due to cirrhosis. Parasitic worms and ova have been seen in European bog bodies and in the New World. Adult hookworms, Ancylostoma duodenale, have been seen in the small intestine of a 1,000-year-old Peruvian mummy. Metabolic and Nutritional Disorders Metabolic diseases may affect the skeleton. A condition of too little bone, osteoporosis, has three major causes: (1) disuse atrophy; (2) a decrease in anabolic hormones, especially in postmenopausal women, and (3) an increase in catabolic hormones, such as androgens or corticosteroids. Affecting the weight-bearing vertebrae predominantly, the bones are thin, light, and weak, and pathologic fractures can occur, causing kyphosis (hunchback), or scoliosis (lateral curvature of the spine), and loss of stature. Excessive production of growth hormone in the adult results in acromegaly, which has been diagnosed in ancient skulls and on some depictions on coins. It has been suggested that the skull of the Pharaoh Akhenaten showed acromegalic changes, perhaps as a manifestation of a multiple endocrine adenopathy syndrome.

A chemical abnormality of bone is the deposition of abnormal elements, such as lead, which concentrates in the brain and kidneys as well. Chronic lead poisoning has been postulated as a factor in the fall of ancient Rome and in the high incidence of gout in Victorian England (lead damage to the kidneys causing decreased uric acid excretion and elevated serum uric acid levels). Calcium can be deposited in tissues under conditions of high blood levels and may occasionally progress to the formation of bone in abnormal areasectopic bone formation. An example is the ossification of the thyroid cartilage seen frequently in ancient skeletal remains. The metabolic disease seen most frequently in paleopathology is porotic hyperostosis, noted above in relation to malaria and other infections. In the prehistoric New World, the disorder has been linked to the transition from hunting and gathering to maize- and grain-based agriculture (El-Najjar, Ryan, Turner, & Lozoff, 1976). Maize, which is very low in usable iron, contains phytic acid, a compound that binds iron in other foodstuffs and reduces its absorption in the intestine. Children require a specific minimum iron intake during the first three years of life and display porotic hyperostosis more frequently than adults. Hyperplasia of the bone marrow, particularly evident in the skull, results in a coral-like external appearance and X-rays show a characteristic hair-on-end change. The lesions seen in ancient specimens closely resemble those seen in contemporary iron deficiency anemia, which is the most common cause of porotic hyperostosis worldwide. Vitamin abnormalities affect the skeleton. Scurvy (vitamin C deficiency) produces subperiosteal hemorrhage and new bone formation. Rickets (vitamin D deficiency) causes osteomalacia, softening and decalcification of the bone, with fractures, bowing deformities, and scoliosis. There is some scattered evidence for rickets, ranging from the possibility of the disease in Homo erectus and (more likely) in Neanderthals to Cro-Magnon and medieval Europe. Some cases have been suggested in Egyptian remains, perhaps related to purdah. An example of hypervitaminosis A has been diagnosed in a 1.5 million-year-old Homo erectus skeleton found in Kenya, probably due to eating raw liver (the ingestion of 400 g a day would be enough to cause the disease). The long bones show a diffuse diaphyseal periosteal bone deposition, consisting of cancellous type bone sharply demarcated from the overlying cortex, with a striking enlargement of the osteocytic lacunae. This was a time before the use of fire, so the liver may well have been a preferential food, as it is easily chewed when rawan illustration of the risks of changes in food sources. Endogenous or exogenous pigments are extraordinarily persistent in ancient remains and thus of great interest in paleopathology. The endogenous pigments are melanin and pigments derived from hemoglobin. An abnormal breakdown product of hemoglobin, hematin, is deposited in the liver and spleen in malaria and has been seen in one Egyptian mummy. Pneumoconiosis is the deposition of exogenous pigments in the lungs, including coal dust or carbon pigment (anthracosis), silicon dioxide (silicosis), iron dust (siderosis), and asbestos fibers (asbestosis). Anthracosis and silicosis have been documented in virtually all civilizations, past and present. Anthracosis usually is due to the inhalation of smoke from open cooking or heating fires, in the home or in industrial settings, while silicosis is due to sandstorms or mining activities. Carbon pigment appears to be relatively inert, but the other pneumoconiosis lead to inflammation and fibrosis and predispose to other diseases, such as tuberculosis and cancer. Immunologic Diseases Although these are serious problems in the modern world (AIDS, lupus erythematosis, etc.), these diseases have not been identified in the paleopathologic record. Degenerative Disease

Osteoarthritis (OA) is probably the best documented disease in paleopathology. It has been described in Neanderthals and in Cro-Magnon and Paleolithic humans. Many Egyptian skeletons show characteristic lesions, indicating that this is truly a wear and tear disorder, rather than being due, as was once thought, to cold damp climates. The disease has also been described in more recent skeletons from Britain and Europe. OA is seen in joints that are used excessively. Examples of this are OA of the temporomandibular joint in populations that employ vigorous mastication of a rough diet, and atlatl elbow seen in native American populations using a throwing stick. Rheumatoid arthritis is a disease of the smaller bones of the hands and feet and the changes are sometimes only radiological, so the diagnosis is difficult in the usual archeological material. An Egyptian mummy has been diagnosed as having gout, with uric acid deposits in the joints. Circulatory Abnormalities Changes in the delivery to the tissues of a normal amount of blood containing the proper amount of electrolytes, nutrients, and oxygen at the proper pressure can result in damage. Infarction is necrosis of tissue due to interruption of the blood supply, usually due to atherosclerosis. Myocardial (heart) and pulmonary (lung) infarcts are often immediately fatal, but they may heal, often with scarring and impaired function. There is considerable paleopathologic evidence of atherosclerosis and Egyptian tomb paintings give evidence of acute myocardial infarction, but experimental studies show that the necrosis of an acute infarct is indistinguishable from postmortem autolysis and thus probably undiagnosable. Cancer This class of diseases is among the most important in industrialized societies. Benign tumors grow slowly, remain localized, and cause only cosmetic or, occasionally, pressure effects. Malignant tumors, or cancers, grow rapidly and have the ability to invade locally and to spread throughout the body, metastasize, causing the death of the individual. The progression of such tumors can be erratic, but, if unchecked by medical or surgical intervention, cancers will metastasize to vital organs via lymphatics or blood vessels, destroying the function of organs such as the liver, lung, or brain and causing death. There have been a number of studies indicating that cancer is a relatively modern disease. Comparative evidence shows that tumors are rare in nonhuman primates. One very early tumor is most likely not a cancer but a benign proliferation of bone of the femur of Homo erectus, the immediate predecessor of Homo sapiens, discovered in Java in the early 20th century. This lesion has been diagnosed as either myositis ossificans, a reaction to trauma, or an example of fluorosis. Identical lesions have been seen in modern patients suffering from excess ingestion of fluorine and similar lesions are noted in sheep grazing in volcanic areas, such as Java. Tumors are mentioned in the Egyptian medical papyri but have been interpreted by modern readers as simply swellings or perhaps varicose veins. Cancers crab-like nature was noted by the Greeks about 200 AD, but the first reports in the scientific literature of a number of distinctive tumors have only been over the past 200 years. Examples include scrotal cancer in chimney sweeps in 1775, nasal cancer in snuff-users in 1761, and Hodgkins disease in 1832. Only one diagnosis of a soft tissue tumor has been reported in a mummyrectal carcinoma in an Egyptian of the 3rd century AD. Tens of thousands of skeletons have been examined and only a few tumor diagnoses made. Osteomas of the skull have been described in several different skeletal populations. Osteochondromas have been diagnosed in skeletons from Scandinavia, Egypt, and in the New World. A medieval skeleton from the Swedish island of Gotland showed multiple exostoses, some of which occluded the pelvic outlet, with death in labor. The unborn fetus showed evidence of the same disease.


Tumors described by Elliot-Smith and Ruffer in Egyptian skeletons as osteosarcoma, primary malignancy of bone, are unlikely to be so, based on the gross morphology. Some more likely cases have been reported from Europe and Peru, although these could be reactive processes, secondary to infection. Osteosarcoma is not an exceptionally rare tumor now and, as it usually produces bone, one might expect it more frequently in archeological material than we do, especially as this is a tumor of young people. Bone is notorious for trapping radioactive minerals and one can speculate on the role of radiation in our modern world in causing bone tumors. Bone can be invaded by local tumors, and bone metastases are common in the modern world but have been diagnosed only rarely in ancient material. Metastatic carcinoma and postmortem erosion can produce similar changes, namely the formation of multiple round defects in the bone. It has been suggested that the short life span of individuals in antiquity precluded the development of cancer. Although this statistical construct is true, many persons did live to a sufficiently advanced age to develop other degenerative diseases, such as atherosclerosis, Pagets disease of bone, and arthritis. It must also be remembered that, in modern populations, bone tumors primarily affect the young. Another explanation for the rarity of tumors in ancient remains is that tumors might not be well preserved, but experimental studies show that mummification preserves the features of malignancy. In an ancient society lacking surgical intervention, evidence of cancer should remain in all cases. The virtual absence of malignancies must be interpreted as indicating their rarity in antiquity. The majority of human cancers are believed to be related to environmental factors, and studies indicating a rarity of cancer in antiquity suggest that such factors are limited to societies affected by modern industrialization. Dental Paleopathology Caries (cavities) is very much a disease of civilization but has probably always been associated with humans and is found in wild apes as well. Caries have been noted in Australopithecines, Homo erectus, and Neanderthals. Neolithic populations show caries in 210% of all teeth. For the Roman period and the middle ages the figure is slightly higher, 514%, but with the increase in the use of more refined sugars and flours in the diet over the past 1,000 years the incidence has risen to the modern figure of 5090%. Caries has an inverse relationship with dental attrition, tooth wear, which has decreased since antiquity. The diet in ancient times contained much grit, as flour or meal was made by grinding wheat or corn on stone slabs X-rays of ancient Egyptian bread have demonstrated significant amounts of grit. Native Americans in the southwest prepared corn meal on a stone mano/ metate and it has been estimated that the average Indian ate three manos and metates in a lifetime. It is common to find ancient teeth worn down to the gumline as a result of this type of diet. As the teeth are worn down, they continue to erupt, socalled supereruption, and can eventually be lost as the roots are exposed. Periodontal disease (pyorrhea) was also more common in antiquity. This condition is an infection involving not only the alveolar bone (the tooth socket) but also the soft tissues of the mouth. Incidence rates on skulls will be underestimates, as minor infections may not involve the bone. The effect of the disease is to cause recession of the alveolus, with loosening and eventual loss of the teeth. The gradual softening of the diet and improved oral hygiene has greatly reduced the incidence of this disease. However, evidence of periodontal disease extends back into the Pleistocene. Enamel hypoplasia is the appearance of depressed bands across the enamel, usually of the incisors. The cause has been related to nutritional deficiency and/ or childhood illness, which are in turn related to social factors. CONCLUSION


The paleopathologic examination of ancient human remains is useful for archeologists, anthropologists, and physicians. Paleopathologic techniques can also be applied to any desiccated tissues, including recent remains, as in forensic settings. For the archeologist there is information on living conditions and social organization. In this context infectious and traumatic conditions are probably of the most interest. Infectious diseases require a certain minimal population living in close contact for their propagation and are thus associated with at least village living, if not urbanization. Disabling diseases, such as arthritis, which take some time to develop, imply a degree of social organization adequate to assume the burden of a cripple. The congenital disorders, such as achondroplasia, have a similar implication. Traumatic injuries tell us about the military or industrial status of a population. Tumors, while of interest to the pathologist studying the evolution of disease, are sporadic and probably of little interest to the archeologist. In general, diseases seen in bones and mummies constitute a reflection of a certain aspect of the population or society under study and can provide information in the same fashion as do pottery or monumental architecture. On the other hand, different patterns of incidence or manifestation of disease can provide information on the evolution of diseases. Paleopathology adds a critical dimension to our study of human history and evolution in relation to the environment.