ACES No.s 1, 2,3 JOURNAL a oF PALEOPATHOLOGY Edited by L. Capasso 2007 ISSN 1120-0200-5 FONDAZIONE fe Rem enectantens Clea unacne mena ‘ea Institute for Bioarchacology NTC een} BISON UROL TES UNDGTABLE OF CONTENTS, JOURNAL OF PALEOPATHOLOGY Vol. 19 No.s 1-3: released March 2008 ARMENTANO N., CARRASCAL S., ISIDRO A., MALGOSA A.: Rheumatic or traumatic etiology?: a case of ankylosis of the elbow. CEccon! E., MALLEGNI F., D’ANASTASIO R.: Endocranial lesions in a subadult of the cemetery of San Sebastiano’s church, Saluzzo, Piedmont, Italy (XV century). CHARON P.: Guidelines for diagnosis in osteo-archacology: usefulness of anatomo-radiologico-clinical comparison (example of osteoplastic conditions in the Dupuytren Museum, Paris). GLEIZE Y., CASTEX D., Dubay H.: An excessive ossification of costal cartilage linked to a traumatici pathology. MESSINA A., SINEO L.: A case of bipartite patella in a paleochristian necropolis in Marsala (Italy). PHILLIPS M. S.: Os odontoideum and neuropathic arthropathy (Charcot’s joint) of the elbow in a male from nineteenth century, U.S.A. SCAPINELLI R., D’ANASTASIO R., Capasso L.: Harris lines in the long bones of the limbs. 63 73Journal of Paleopathology University Museum State University “G. d’Annunzio” 66100 - Chieti (Italy) Volume 19 No.s 1, 2,3 2007 Car ae FONDAZIONE CARICHIETI parhally supper ty oa) for: SAN FRANCISCO, CA (USA) @ ‘The Ministry for Cultural and Environmental Heritage classifies the Journal of Paleopathology as a publication of high cultural value (Art. 25, Law 8-5-1981, n, 416, and Art. 18, Law 2-25-1987, n. 67). I] Ministero per i Beni ¢ le Attivita Culturali riconosce il Journal of Paleopathology come un periodico di alto valore culturale, ai sensi dell’ Art. 25, Legge 5-8-1981, n. 416 ¢ dell’ Art. 18, Legge 25-2-1987, n. 67. The Journal of Paleopaihology is registered to National Printing Register (Art. 11, Law 416/81) at the number 06031 Il Journal of Paleopathology & iscritto al Registro Nazionale della Stampa (Art. 11, Legge 416/81) con il numero 06031 Published by Tecnovadue — Chieti (Italy)EDITOR Luigi Capasso (Italy). EDITORIAL BOARD Alexeeva Tatiana (Russia); Arthur C. Aufderheide (U.S.A.); Don R. Brothwell (England); Domingo Campillo (Spain); Luigi Capasso (Italy); Arnaldo Capelli (Italy); + Eve Cockburn (US.A.); + Jean Dastugue (France); Gino Fornaciari (Italy); Judyta Gladykowska-Rzeczycka (Poland); + Mirko D. Grmek (France); + Paul A. Janssens (Belgium); Antonia Maresik (Hungary); Renato Mariani-Costantini (Italy); Donald J. Ortner (U.S.A.); Friedrich W. Résing (Germany); Michael Schultz (Germany); Ted R. Steinbock (U.S.A.); Eugen Strouhal (Czech Republic). COPY EDITOR Mary Lucas Powell (U.S.A.). PUBLISHER Tecnovadue - Chieti Scalo - 66013 Chieti (Italy). EDITORIAL SECRETARY Antonietta Di Fabrizio (Italy), Elisabetta Michetti (Italy) and Rossano Angelini (Italy). ADDRESSES Business address: all business mail, including subscriptions, book and issue orders, and payments, should be addressed to: Journal of Paleopathology - University Museum, State University “G. d’Annunzio” - Piazza Trento e Trieste - 66100 Chieti (Italy) Scientific address: all scientific mail, including submissions of original papers for publi- cation, books to review, and off-print orders and payments, should be addressed Journal of Paleopathology - University Museum, State University “G. d’Annunzio’ 66100 Chieti (Italy) or to: anthropos@unich.it Publication data: Journal of Paleopathology is published 3 issues annually. Subscription rates: subscriptions run for a full volume, (not necessary corresponding to calendar year). Prices are given per volume, surface postage included — Personal or institutional subscription: 90 €. Single issues and back volumes: information on availability and prices can be obtained through the Editorial Secretary. Book reviews: books are accepted for review by special agreement.KEY TO THE GRAPHIC SYMBOLS, =) Ga) () &) Bo [| BS) I (7) ©) Methods in paleopathology Chemical, biochemical and molecular studies Skeletal dysplasias Trauma Endocrine disturbances Paleoparasitology Reticuloendothelial and hemopoietic disorders Lesions of the joints Mcchanical deformities Non human and comparative pathology Paleonutrition and stress indicators Lectures BONS OBYHewsOBBe Studies on mummified materials Studies on written and artistic sources Skeletal malformations Metabolic disorders Infectious diseases Circulatory disturbances Other diseases Tumors Paleoepidemiology Ancient history of medicine and artificial lesions Lesions of jaws and teeth Book reviewDirettore Responsabile: Luigi Capasso Aut. Trib. TE N. 338 del 3 luglio 1992 The Journal of Paleopathology is registered to National Printing Register (Art. 11, Law 416/81) as the number 06031 Journal of Paleopathology Vol. 19, No.s 1, 2,3 - 2007 © 2008 by Associazione Antropologica Abruzzese Journal of Paleopathology. Via dei Tintori, 1 66100 Chieti (Italy) All rights reserved for all CountriesJo. 19 (1-3) 2007: 5-10 RHEUMATIC OR TRAUMATIC ETIOLOGY?: A CASE OF ANKYLOSIS OF THE ELBOW N. Armentano” S. Carrascal A. Isidro” | A. Malgosa Abstract. We present a case of ankylosis in flexion of the left elbow of an individual from the 14th century. The skeleton of a mature woman was found in the cloister of the Monastery of Sant Cugat del Vallés (Barcelona, Spain). The arm is completely fused between the humerus and the ulna, flexed in the semipronated position. The differential diagnosis suggests that the lesion is possibly due to rheumatoid arthritis; alternatively, it may have resulted from trauma. Introduction. The individual we present here was. recovered from burial number 7 (STC.CLS 3041) during archacological excavations carried out in 2001-2002 in the Cloister of the Monastery of Sant Cugat del Vallés (Vallés Occidental, Barcelona). — This Benedictine Monastery (Fig. 1) is a Romanesque basilica. The cloister, built at the end of the 12th century (Fig. 2), is being the most important architectural element in Sant Cugat. The individual was recovered from this cloister out of context: it had already been discovered, but not exhumed, at the beginning of the 20th century, but the area was not fully excavated until very recently. Individual description. The skeleton belongs to a female individual from the later part of the 14th century. The state of preservation (Walker & al., 1988) is good, around 71.4%; however, the skeleton lacks the inferior extremities. The characteristics of the skull, jaw, and coxal bones were used to determine sex (Ferembach & al., 1980, Aleman & al., 1997), in *Unitat d’Antropologia. Departament de Biologia Animal, Biologia Vegetal, i Ecologia, Universitat Auténoma de Barcelona, Barcelona, Spain. ** Hospital de! Sagrat Cor, Barcelona, Spain.Figure 1. View of the Sant Cugat del Valles Monastery (Vallés Occidental, Barcelona). addition to the conventional approaches of Martin and Saller (1975) and Oliver (1960) that take into account robustness, size, and muscular relief of the postcranial bones and metric data from the long bones. The individual’s age (probably older than 45) was determined both by the degree of cranial suture obliteration (Masset, 1982) and by dental wear (Brothwell, 1987). Other diagnostic elements are not well preserved. The individual’s height has been estimated to be 163.7 em, according to Pearson (Oliver, 1960). The anthropological study showed some degenerative lesions: osteo- arthritis and fusion in several parts of the posteranial skeleton. @ ] ] Ny} LI U Figure 2. Plant of the excavations of the Cloister of the Sant Cugat Monastery during 2001-2002, Enthesopatic formations can be observed especially on the iliac crests, as well as on the ischial tuberosity of the pelvis. Osteoarthritis is observed in the dorsal side of the sacrum, the distal epiphysis of the right humerus, the proximal right ulna and radius, and in some of the distal phalanxes of the hands. We also observed some fusions between the 2"¢ and 3" cervical vertebrae and in the left superior extremity, which displays ankylosis in the flexied, semipronated elbow without including the radius (Fig. 3). Description of the lesion. Macroscopic Description. The ankylosis in the left elbow shows a complete fusion of the 6 Journal of Paleopathology 19 (1-3)re 3. The skeleton STC.CLS 3041 showing the afiected articulations. In circle: osteophytic formations. In square: ankylosis, Figure 4. Medial view of the fusion of distal of the left humerus and proximal of the left ulna, humerus and the ulna in semipronated flexion (Fig. 4). Both the ulna and the radius are complete and show normal morpho- logy, while the humerus has a post- mortem fracture in the medial part of the diaphysis. The distal epiphysis of the humerus is not visible because of the ankylosis and the pseudoacetabular formation of the articular surface of the ulna which articulates with the radius head (Figs. 5 and 6). The measurements of the superior limb are listed in figure 7. The robusticity indices of the two radii (16.19 and 17.65; Olivier, 1960) describe bones from an individual with a gracile body structure. Description of the X-Ray. The X-Ray shows complete fusion of the humerus and ulna. It can be seen that the articulation has healed in the correct (ie., physiological) position, The radiological characteristics of the bone show no changes around the lesion nor any in the rest of the humerus, ulna, or radius diaphyseal shafis. The CT image shows that the interline joint totally disappeared, while a hypertrophic area at the proximal articulation between the radius and ulna can be observed. In this case, the ulna articular surface for the radius and its ligament form a false socket to prevent this joint from dislocating during the prono-supination movement. Journal of Paleopathology 19 (1-3)Figure 5. Cavity developed in the distal epiphysis Of the left humerus fo joint with the radius neck Diagnosis. We suggest two possible dia- gnoses: a traumatic fracture during life followed by fusion of the joint in a good semipronation flexion, or an ankylosing arthropathy compatible with unilateral rheumatoid arthritis The diagnosis of rheumatoid arthritis is more difficult because, although the morphologic alteration of the joint is compatible with this rheumatic illness, arthritis normally affects multiple articulations symmetrically. The skeleton also shows other skeletal pathology compatible with degen- erative osteoarticular disease, but there are no etiologic parallels with the left elbow. There is no symmetry in this case, although this would be expected in a case of arthritis: only the left arm is affected. In general, it is not easy to assess rheumatoid arthritis in paleopathology and such assessment requires the entire skeleton with all Figure 6 New bone crest developed in the olecranian zone of the uln phalanges of the hands and fect because arthropathy in the distal phalanx is due to osteoarthritis. We do not have the complete skeleton or the smaller bones such as the metacarpals and phalanxes. In spite of the difficulty in making a diagnosis, however, it can be seen that the elbow, metacarpals, and phalanxes are the most affected parts of the body (Cunha, 2003). The factors in favour of the post- traumatic diagnosis are: 1) traumatic lesions usually occur unilaterally; 2) the lack of movement (although the articular cartilage is damaged, it may represent ankylosis secondary to an articular fracture); and 3) the other signs of arthritis in the skeleton could be the consequence of the probable mature age of the individual. The factors against diagnosing an ankylosis caused by a post-traumatic fusion are: 1) no fracture or fissure line can be observed, either macrosco- Journal of Paleopathology 19 (1-3)HUMERUS RIGHT | LEFT Transverse diameter of the head nm. 44 Vertical diameter of the head nm. 3 ULNA RIGHT | LEFT Widih of the lower epiphysis 19 15 RADIUS RIGHT | LEFT Maximum length 238 | 247 Physiological length 203 225 Minimum perimeter 2 40 Half perimeter 4 4 Minimum half-diameter ll 10 Maximum half-diameter 16 7 Width of the lower Epiphysis 32 31 Perimeter of the radial tuberosity 31 31 n.m.= not measurable Figure 7. Measurements of the superior limb. pically or with X-ray or CT images; 2) the absence of osteophytosis; and 3) the absence of signs of secondary overload in the distal and proximal joints (shoulder and wrist) Characteristics that support a diagnosis of RA are: 1) the morpho- logical characteristics of the lesion, and 2) the sex (female) and age of the individual. The factors against rheumatoid arthritis are: 1) the fusion is unilateral; 2) the other peripheral joints that could be slightly affected by rheumatic pathologies are not affected; and 3) the low probability that such a complex Journal of Paleopathology 19 (1-3)alteration in a joint such as the elbow could be the first and/or only articular sign of RA or a similar illness. Favourable and non-favourable factors in this differential diagnosis are more or less balanced. For this reason, there is some doubt involved in diagnosing this case. References. Alemén [ Botella M C & Ruiz L 1997 Determinacién del sexo en el esqueleto posterancal Estudio de una poblacién mediteminea actual Archivo Espaitol de Morfologia 2: 2-17. Brothwell D R 1987 Desenterrando huesos Fondo de Cultura Eeonémica Méxic Cunha E 2003 Aproximacién paleopatolégica de algunas enfermedades reumaticas In Isidro A Malgosa A Eds Paleopaiologia, la enfermedad no escrita 209-220 Ed Masson Barcelona. Ferembach D Sehwidetzky I & Stloukal M 1980 Recommendations for Age and Sex Diagnoses of Skeletons Journal of Human Evolution 9: 517-549 Akadémiai Kiadé Budapest. Martin R & Saller K_ 1957 Lehrbuch der Anthropologie Ed G Fisher Stuttgart. Masset C 1982 Estimation de I’age au décés par les sutures cranicnnes Thése Université Paris VIL Oliver G 1960 Pratique Anthropologique Vigot Frores Eds Paris. Walker PL Johnson J R & Lambert P M 1988 Age and Sex Biases in the Preservation of Human Skeletal Remains American Journal of Physical Anthropology 76: 183-188. 10 Journal of Paleopathology 19 (1-3)JoP. 19 (1-3) 2007: 11-18 ENDOCRANIAL LESIONS IN A SUBADULT OF THE CEMETERY OF SAN SEBASTIANO’S CHURCH, SALUZZO, PIEDMONT, ITALY (XV CENTURY) E. Cecconi”™ F.Mallegni R. D’Anastasio Abstract. The skeletal remains belong to the cemetery of San Sebastiano’s church in Saluzzo (Piedmont, Italy, XV century). The Kingdom of France and the Duchy of Savoia, therefore always contended the Marquisate of Saluzzo. Especially during XV century it underwent numerous invasions, attacks and sieges. The T9 individual is an infant of 2,5 years of age. She/he presents endocranial lesions located in frontal bone, parietal bones, and occipital bone, moreover with involvement of the orbits. This is the expression of a hemorrhage/inflammation of the meninges. The particular historical context suggests that probable different but correlated concomitant causes, as scurvy, infectious diseases, and traumas, could have played an important role in the T9 individual pathological condition. Introduction. beginning of XVI century) the From March to June 2003, a series of archaeological investigations has been carried out inside the ex-bishop’s palace of Saluzzo by the Soprinten- denza per i Beni Archeologici del Piemonte. The site was originally occupied by the church of San Sebastiano, built in 1403 after an epidemic of plague to release the citizens from a vow. For about a century (ic. from 1403 to the church cemetery was used as burial- ground. This period, however, has been too short to induce a clear subdivision in distinct chronological phases. The high superimposing of burials and the shortage of floor levels have also contributed in complicating the stratigraphical analysis of the site. Materials and methods. The T9 individual is about 2,5 “Department of Biology, University of Pisa, Italy. Laboratory of Anthropology, School of Medicine and Surgery, University “G. d'Annunzio”, Chieti, lalyFigure 1. Deposition of T9 individual years old (Ubelaker, 1978). According to the archaeological data, her/his burial (E-W orientation) was cut by an adjacent deposition (Fig. 1). The skull is bowed to the left, probably maintaining its original position. The maxilla and the frontal bone (still not joined) have slid to the mandible. The clavicles are strongly vertical. Probably a secondary taphonomic factor has displaced the right scapula (Mallegni & Rubini, 1994; Duday & Masset, 1987; Duday & al., 1990). The right hemitorax is closed and pulled down. On the contrary, the left hemitorax is open: this allows us to infer the presence of some concavity of the grave in this point. The upper limbs are spread and quite close to the hips. The right radio and ulna are displaced, whereas the humerus is in the original position. The inner surface of the grave has probably constricted the left limb permitting it to preserve its original position. The carpal and metacarpal bones have fallen inside the pelvis, that is considerably open. The right coxal has fallen laterally. The femora are frontally rotated and the fibulae and the tibiae are distinctly displaced from the articulation of the knees. The lower extremities are lost probably because of the cut of the adjacent burial. The position of the skeleton, the spreading of the lower limbs, and at the proximity of the upper limbs to the thorax, make it plausible to argue the presence of a sudarium or swaddling bands. Discussion and conclusions. The T9 individual presents endo- 12 Journal of Paleopathology 19 (1-3)cranial lesions (the external surface is uninjured) at the frontal bone (Fig. 2a), at the parietal bones (Fig. 2b), at the occipital bone, and moreover at the orbits (Fig. 2c). The temporal bone and maxilla are porous and the sphenoid bone is unaffected. The lower limbs appear porous. The cranial lesions of the T9 individual are quite peculiar and different in respect of porotic hyperostosis. However we can not exclude the more severe condition of this affection categorized in Keenleyside, Panayotova (2006) Figure 2. T9 individual. Frontal bone (2a); right parictal bone (2b); left orbit (2c). (“stage 4”), consequently we can not exclude that a deficient diet, diarrhea, and gastrointestinal hemorrhages could be at the origin of the bone reaction. Moreover according to some authors (Stuart-Macadam & Kent, 1992) iron deficiency could be an immunization against a possible bacterial prolife- ration. It is defined “physiological iron lack” and typically occurs to infants between the ages of 6 and 18 months (after weaning). In this period children are more exposed to the bacterial infections, since the antibody contri- bute of maternal milk decreases. Journal of Paleopathology 19 (1-3) 1BConsequently, to prevent bacterial proliferation, which increases with iron assimilation, it may happen that an individual will develop iron deficiency (Stuart-Macadam & Kent, 1992). On the other hand the absence of external surface injuries, the fact that the internal lesions are bone proliferations and rarefactions that follow the development of the vascular system (Lewis, 2004; Hershkovitz & al., 2002), their location and their symmetric distribution with no ectocranial involvement lead us to an alternative diagnosis. The endocranial bone reaction in non-adult is a condition, which has recently attracted attention in literature (Lewis, 2004; Hershkovitz & al., 2002, Schultz, 2001). Several aetiologies, including chronic meningitis, traumas, neoplasia, scurvy, rickets, tuberculosis, have been suggested. They can cause inflam- mation and/or hemorrhage of the meningeal vessels (Lewis, 2004), In the present case, the opinion of experts, helped us to conclude that most likely the lesions originate from a hemor- rhagic epidural process, which determined an inflammation of the dura mater (which, especially in children, has reactive processes analogous to those of the periosteal bone). Therefore it is possible to suggest a pachymeningitis form. A microscopic analysis showed a complex ramification produced by the development of meningeal vessels, which is a consequence of the haematoma. Some blood vessels are characterized by the presence of an extra groove. Such morphology originates from a change in the diameter of the involved vessels and it is consequent to a collapse of their walls. This evidence also suggested that the individual survived for a certain time after the formation of the hemorrhage and the inflammation. Therefore it has been diagnosed an epidural haematoma located on the endocranial surface of frontal and parietal bones (with involvement of the orbits) with consequent inflammation of the meninges. The meningitis is an acute inflammation of the meninges by definition, but it can have various aetiologies. The most common infec- tions are caused from Haemophilus influenzae and __‘Streptoco pneumoniae. Instead the secondary infections can result from infections of the upper and lower respiratory tracts, otitis media, mastoiditis, sinusitis (Hershkovitz & al., 2002); or from other infections: typhoid fever, gastroenteritis, measles and pertussis (septic infections) (Lewis, 2004). The specific meningitis results also from the Mycobacterium tuberculosis, both of pulmonary and __ gastrointestinal form. About 1-2% of meningitis results from secondary stages of venereal syphilis. The above-mentioned menin- geal inflammation forms usually produce reaction of the arachnoid and pia mater (leptomeningitis). Further- more, it has been observed that in TB 14 Journal of Paleopathology 19 (1-3)inflammation the lesions are more lytic, with new bone formation and vascular impression on the arachnoid and involvement of the cranial base. For these reasons this specific infections seem not to have correlations with the case described here. The epidural haematoma could be caused by a trauma or by a metabolic pathology such as scurvy. Even though bacterial infections can not be excluded. Since scurvy can create immunodeficiency it is often associated with infectious diseases. Moreover, since a defective collagen synthesis follows from scurvy, an extreme weakness of the bone is registered making it more subject to traumas. Frequently, in paleopatho- logical samples, an epidural haematoma is not distinguishable from a subdural one (Kleinman, in Lewis, 2004). Subdural and epidural hemorrhages are common in the first two years of life (birth trauma or postnatal trauma). In literature (Caffey, in Lewis, 2004) subdural hemorrhages, which involve also the orbits, have been described as indicative of abuse. Even though cranial fractures are not ible, it has been suggested that the violent whiplash, produced by the shaking, would cause the detachment and the separation of the dura mater from the skull, with consequent hemorrhage. Vitamin deficiencies. (especially vitamin C deficiency) are considered predisposing factors to the cranial lesions (Lewis, 2004). As Melikian, Waldron (2003), suggest, there are no specific skeletal signs of scurvy, but some changes was attributed to this disease. They include deposition of new bone on the skull, pathological changes on periodontal tissues (Mogle & Zias, 1995), periostitis, and alteration in the morphology of the metaphyses of long bones. However Hershkovitz et al. (2002) affirm that the lesions associated with scurvy and other metabolic disorders do not affect the endocranial surface and Ortner et al. (2001) have suggested that the most common expression of scurvy are the porous lesions on the surface of the sphenoid bone and that other skeletal lesions without sphenoid involving are uncommon. The scurvy is a condition caused by lack of vitamin C, which results in defective collagen synthesis with consequent delay of the skeleton growth and hemorrhages. While the majority of the mammals produce vitamin C from glucose, humans (together with a few monkeys and with piglets of India) are not able to produce it. Vitamin C is indispensable for formation of collagen and for the maintenance of bone and dental connective integrity. It is also essential for healing injuries. Moreover it enters in the metabolism of the folic acid and regulates the absorption of the iron. Therefore ascorbic acid deficiency produces disorders in osteoid formation, with effects in the skeleton growth of non-adults. Such deficiency Journal of Paleopathology 19 (1-3) 15also induces lack of integrity of the walls of the blood vessels that could result in spontaneous or induced by light traumas subperiosteal hemor- thages (Ortner, 2003). Hemorthages in encephalic area are determinant for the diagnosis on the T9 individual. These are common processes, which are typically lethal. They appear slowly and stimulate the osteoblastic activity (Aufderheide & Rodriguez-Martin, 1998). If a hemorrhagic proc happens in the subperiosteal area of the orbital plate, it can cause staring eyes (exoftalmia) (Aufderheide, Rodriguez- Martin, 1998). It is worth noticing that traumas to brain and eyes caused by abuses appear with haematoma and new bone formations, which are similar to those caused by scurvy. In our diagnosis, however, we tend to exclude traumas since the correspond- ding lesions are typically monolateral and are often accompanied with periostitis of the limbs and with costal fractures (Lewis, 2004); therefore Hershkovitz et al. (2002) affirm that subdural haematoma produce osseous plaques on the endocranial surface without labyrinthine appearance. Ortner (2003) suggests that the hemorrhage from scurvy and the associated bone formation is linked to trauma. Moreover Schultz (2001) affirms that the alterations caused by scurvy are found on the shaft of long bones, on the ectocranial and some- times on the endocranial surface of the skull. The deficiency in only one vitamin is not a common condition; therefore it is necessary to consider a combined nutritional deficiency (espe- cially proteic). About 4% of vitamin C is destroyed or lost by normal catabolism and the symptoms appear 1-3 months after the complete cessation of the reserves (Aufderheide & Rodriguez-Martin, 1998). Unless the mother is suffering from scurvy, vitamin C deficiency rarely occurs in neonates because ascorbic acid passes through the placenta to the fetus. In infants, scurvy has been rarely observed before 4 months of age and reaches its maximum incidence be- tween 8 and 10 months of age (Ortner, 2003). Apart from being considered a typical affection of ancient ship’s crews, scurvy is also linked to periods of siege, war and famines. The isolation of the populations for long periods can stop the supply of certain foods (Ortner, 2003). Particularly during the sieges, the closure inside city walls prevents victuals coming from the countryside’s (Mazzi, 1981) Since the poorest usually eat salted and preserved meat (then with total loss of vitamin C) and follow, often forced by indigence, a monotonous diet, their exposure to scurvy is high. On the other hand the richest classes were avoiding the use of fresh and raw fruits and vegetables, while preferring a proteinic diet as a distinguishing sign of the membership class (Comba & al., 1996: Nada Patrone, 1981). This historical condition and lifestyle has 16 Journal of Paleopathology 19 (1-3)been confirmed by written sources and by nutritional investigations, which show that the San Sebastiano population was distinct in two different classes characterized by proteinic and essentially vegetable diet, respectively (Cecconi, 2007). Moreover during the late Middle Ages the Marquisate of Saluzzo had a very important strategic position, being located between the Kingdom of France and the powerful Duchy of Savoia. For this reason, it was subject to continuous sieges, attacks and invasions. Therefore it was suggested that vitamin deficiencies, in particular vitamin C deficiency, affect- ed the San Sebastiano population. This hypothesis is corroborated by the diagnosis of T9 individual and by the other cases of serious haematoma (on the lower limbs especially) discovered in the sample (15,6% of the sample). In literature are not registered endocranial lesions as particular expression of scurvy. In T9 individual changes as sphenoid bone porosity are not visible; there is no evidence of trauma or fractures; we can not be sure that non- specific infections affect the infant. However, since scurvy can create immunodeficiency it is often associated with infectious diseases; moreover an extreme weakness of the bone is registered making it more subject to traumas. Therefore the peculiar historical context suggest that probable different but correlated concomitant causes could have played an important role in the T9 individual pathological condition: deficient diet, vitamin deficiency, lack of iron, immunodeficiency, infectious diseases, diseases of upper and lower respiratory tracts, and traumas. Acknowledgements. ‘The authors thank Egle Micheletto and Laura Maffeis, Soprintendenza per i Beni Archeologici del Piemonte. Mary Lewis, Senior Lecturer in Forensic Archaeology “and Anthropology, School of Conservation Sciences, Bournemouth University for her professional opinion; Professor Israel Hershkovitz, Department of Anatomy and Anthropology, Faculty of Medicine, Tel Aviv University, Ramat Aviv, Istacl, Dr. Vincenzo Reparto di Radiologia, Clinica “Villa Serena”, Pescara, Italy; Dr. Fulvio Bartoli, Dipartimento di Scienze Archeologiche, Pisa, Italy, for analyzing the concentration of elements by AAS; Dr. Vittorio Giovannetti for reading the English-language text. References. Aufidetheide A C & Rodriguez-Martin C 1998 Cambridge Encyclopaedia of Human Paleo- pathology Cambridge Comba R Nada Patrone A M & Naso I 1996 La ‘mensa del principe: cucina ¢ regimi alimentari nelle corti sabaude XHI-XY secolo Cuneo. Duday H & Masset C 1987 Anthropologie Physique et Archéologie. Methodes d’étude des sepoltures Paris. Duday H Courtaud P Crubézy E Sellier P & Tillier A M_ 1990 L’anthropologie “de _ terrain” Teconnaissance et interprétation des _gestes. funéraires Bull Et Mém Soc d'Anthropol De Paris 3- 4: 29-50. Hershkovitz I Greenwald C M Latimer B Jellema $ WB Eshed V Dutour 0 & Rothschild B M 2002 Journal of Paleopathology 19 (1-3) 7Serpens Endocrania Simmetrica (SES): a new term and a possible clue for identifying intrathoracic diseases in skeletal population 4m J Phys Anthropol 118 (3): 201-216, Lewis ME 2004 Endocranial lesions in non-adult skeletons: understanding their aetiology Int J Osteoarchaeol 14: 82-91 Mallegni F & Rubini M 1994 Recupero dei materiali scheletrici umani in archeologia Roma. Mazzi M S 1981 Consumi alimentari ¢ malattie nel Basso Medioevo Archeologia Medievale VII Melikian M & Waldron T 2003 An exami skulls from two British sites for possible evidence of scurvy Int J Osteoarchaeol 13: 207-212. Mogle P & Zias J 1995 Trephination as a possibile treatment for scurvy in a Middle Bronze Age (ca 2200 BC) skeleton int J Osteoarchaeol 5: 77-81. Nada Patrone A M 1981 I! cibo del rieco ¢ il cibo de! povero Contribute alla storia qualitativa dell’alimentazione. L’area_ pedemontana negli ultimi secoli del Medio Evo Torino, Ontner D J Butler W Cafarella & J Milligan L 2001 Evidence of probable scurvy in subadults from archacological sites in North America Am J Phys Anthropol 114: 343-351. Ortner D J 2003 Identification of pathological conditions in human skeletal remains Washington. Schultz M 2001 Paleohistopathology of bone: a new approach to the study of ancient diseases Yearbook of Phys Anthropol 44: 106-147. Stuart-Macadam P Kent S 1992 Diet, demography and disease: changing perspectives of anemia. Ubelaker D H 1978 Human skeletal remains: excavation, analysis, interpretation Washington. 18 Journal of Paleopathology 19 (1-3)J.o.P. 19 (1-3) 2007: 19-46 GUIDELINES FOR DIAGNOSIS IN OSTEO-ARCHAEOLOGY: USEFULNESS OF ANATOMO-RADIOLOGICO-CLINICAL COMPARISON (EXAMPLE OF OSTEOPLASTIC CONDITIONS IN THE DUPUYTREN MUSEUM, PARIS) P. Charon * Abstract. Some anatomical, radiological, and clinical (or medico-historical) examples of skeletal pathology found in the Dupuytren Museum at Paris include several osteoplastic conditions, including hyperostosis frontalis interna, fibrous dysplasia of bones, osteoma, osteochondroma, intra-osseous angioma and osteosarcoma, demonstrate how these three categories of information help to establish accurate image guidelines, useful for osteo-archaeologists who do not have clinical information, and how it emphasizes the necessity for supporting and sustaining such pathological anatomy museums. Introduction. The process of osteoarchacological diagnosis is based on observing and identifying pathological lesions in osteoarchaeological materials, founded on gross anatomical and radiological examination of the bony specimens in question. Of course, archaeological (site, date, population burial patterns) and anthropological (age at death, sex, osteometry, anatomical variations) information, when available, are essential prerequisites. The difficulties of this process are well known, as the nature and state of the bony material may vary in preservation (more or less broken, fragmented, or incomplete) and of bony lesions, either solitary or multiple. So, within the rich nosology of osteo-articular diseases or others that leave traces on the skeleton, we are often able only to recognize an osteoarchacological syndrome or to hesitate between several retrospective diagnoses. Consequently, in palaeo- pathological reports, the discussion of differential diagnosis and/or the probabilistic nature of positive dia~ gnosis is often extensive. Thus the palaeopathological community * Ecole Pratique des Hautes Etudes, Ie section Sciences historiques et philologiques, La Sorbonne, Paris, France.has endeavoured to create guidelines for gross anatomical and radiological images, as testified by the numerous treatises on palaeopathology published during the second half of the XXth century (Ubelaker, 1978, 1989; Ortner & Putschar, 1981; Dastugue & Gervais, 1992; Aufderheide & Rodriguez-Martin, 1995; Thillaud, 1996). To this same end, Campillo recently provided a very interesting compilation of radiological images showing anatomical variability, hered- itary and congenital malformations, and neoplastic conditions (Campillo, 2005 a, b, c). (We will not discuss here the chemical, serological, genetic, and histological data which are also important for diagnosis but frequently not available.) For this purpose, the comparison of images of pathological specimens with data from clinical history (which clearly is impossible in the field but sometimes accessible and useful for documented pieces in large museums of pathological anatomy) is able to give us precious additional information for positive diagnosis, as does the anatomo-clinical method which holds a major place in medical practice since XIXth century. That is an additional reason for carefully protecting such collections. Previously we studied skeletal exostoses (in sensu Jato) in the Dupuytren museum collections (Charon, 1996) in order to suggest the production of an illustrated osteo- archaeological catalogue. It seems useful now to present some examples for developing osteoarchacological image guidelines supported by this triple comparison, without any claim to exhaustivity, of course. Dupuytren Museum in Paris. When Guillaume Dupuytren died in 1835, there existed in Paris neither chair nor museum for pathological anatomy, but only a little gallery, which would later become the Orfila Museum. Anatomy prosector in 1795, Manager of the anatomical works in 1798, and Surgeon of the H6tel-Dieu in 1802, he declared, in his doctoral thesis, that Pathological Anatomy was the essen- tial factor for medical progress. He founded in 1803 the Anatomical Society, but unfortunately did not publish his Pathological Anatomy treatise. In 1834, he wrote a testament in which he bequeathed a part of his wealth (200,000 gold francs) in order to establish a Chair of Pathological Anatomy. However, this amount was not enough, and Orfila suggested that he modify his testament in order to devote this amount instead to establishing a Pathological Anatomy museum. After Dupuytren’s death, Orfila persuaded the French govern- ment to found both a museum in his name and a Chair dedicated to teaching this branch of medicine. When the museum foundation was created, a number of anatomo- 20 Journal of Paleopathology 19 (1-3)pathological pieces from the Medical Faculty’s gallery and those collected at Hétel-Dieu by Dupuytren himself were brought to it. This collection continued to grow: in 1842, Houel says, the Museum contained close to 1000 pieces, 765 of them described in the catalogue published by Denonvilliers & Lacroix constituting two volumes and one atlas, exclusively dedicated to bone diseases (Denonvilliers & Lacroix, 1842). Houel, the curator of the Orfila and Dupuytren Museum, devoted a large part of his activity to enrichment of the museum collections, which had reached nearly 6000 pieces when, in 1877, he published a detailed and illustrated catalogue, containing ab- stracts of clinical observations for a number of cases (Houel, 1877). During further decades, specimens from several clinics, like the one directed by Odilon Marie-Lannelongue, were incorporated into these collections to enrich them. Unfortunately, after Houel’s death in 1881, the rooms of the Museum were not kept in repair, with the result that in 1937 it was necessary to dismantle them and the specimens were stored, mostly without sufficient care, into cellars and some specimens were employed for pathological anatomy practical works. During 1967, the Museum was reinstalled in a wing of the Ecole Pratique, now the Centre Universitaire des Cordeliers, under the care of J. Delarue, R. Abelanet and P. P. de Saint-Maur, and completed by pieces from the Djerine collection and Antonin Gosset laboratory pieces from La Salpétrigre (Abelanet, 1990: Abelanet & de Saint-Maur, 1991; Abelanet, 1993). Today (the curator of the Dupuytren Museum today is Dr Patrice Josset) the present collections include: -some woodcarvings from the Collége Royal de Chirurgie; -whole skeletons and very numerous isolated pieces, some of them irreplaceable examples of pathologies now disappeared from the Western world. It is in these true treasures that the palaeopathologist can find a very rich osteological iconography; -several wax sculptures (some prior to 1800) and others of plaster, cardboard, and revarnished papier maché; glass jars, some of them containing pathologies no longer seen today; -normal and pathological histology preparations from the Déjerine collection, and a rich library collection containing numerous ancient books, most of them XIXth century Pa- thological Anatomy treatises; and Proceedings of the Société d’ Anatomie meetings with its album. Guidelines. J-Hyperostosis frontalis interna. Known since Morgagni, of still undeterminate cause, with a large female sex-ratio, it is described in medical treatises as “an abnormal bony proliferation located on the internal Journal of Paleopathology 19 (\-3) 21side of frontal squamas, typically symmetrically set upon and restricted to the two halves of the frontal bone, respecting the coronal and metopic sutures, the falx of cerebrum insertion, middle meningeal artery grooves, and horizontal part of frontal bones. In a way, it raises the inner table by an irregular protrusion similar to “moun- tainous country relief”. At section it is seen that the outer table remains normal; but the diploé is significantly thickened and the inner table, which is thinned, is irregularly elevated by this thickening, easily raised by 10-15 mm and even more than 30 mm. In lateral radiographs, the outer table of the frontal squama has a normal outline but, beneath it, in place of the diploé and the inner table, is seen the picture of a more or less irregularly embossed bony neoformation protruding endo- cranially” (De Séze & Ryckewaert, 1972). This specimen is a good example. 1-1-Museum specimen n° 370-A. Gross anatomical examination. Skull cap of an adult, of middle or advanced age, with fused endocranial sutures, undeterminate sex, good preservation, containing the frontal squama, both parictals, the temporal squamas and the superior part of the temporal bones. No abnormality appears on the external side of the piece. Two bony neoplastic processes are seen on the inner surface of the frontal squama at each side of medial line. Size: (right) 30 mm length, 20 mm width and 18 mm thickness and (left) 40, 20, and 18 mm, respectively. Their surface is irregular, mamelonated, and composed of very compact bone. At this point, the frontal bone is 6 mm thick. A transverse cutting line crosses through these two “tumors” but cross- sectional lateral views of the morpho- logy is not visible because of the assembly of the specimen (Fig. 1). Radiological examination. In front view, two polycyclic, low density, opacities are seen at each side of the medial line separated by a low lucent vertical area; the lateral radiographic view shows inner table protrusion and diploé thickening with increased density, without outer table participa- tion. Medico-historical data. In Houel’s catalogue we can read an interesting description of the cross-sectional appearance in a fresh state: “exostoses are reddish grainy diploé-like tissue covered at the surface by a thin compact bone layer. A white line separates the bone from the two tumors’ tissue, so as to suggest that they developed upon the existing bone surface and not inside” (Houel, 1877). Diagnosis. The anatomical and radiological aspects are very suggestive of hyperostosis frontalis interna, because of the virtually symmetric bilaterality and the topo- graphy respecting the median line and falx cerebrum insertion. Osteomas can be ruled out because of these topo- 22 Journal of Paleopathology 19 (1-3)graphic data and the lack of peripheral involvement. The description of the appearance of the fresh state also excludes osteomas, by showing that its internal structure is similar to diploé, not compact bone. Figure 1. Hyperostosis frontalis interna, a- photograph, endocranial view. b- radiograph, superior view. I-Fibrous dysplasia of bone. The Dupuytren Museum shows several examples of facial bones affected by this disease, prevalent in the female sex and often beginning in childhood or the teenage years. More often located in the limbs, it is sometimes local and mono-osseous, and sometimes more extensive, often monomelic, but never generalized to the whole skeleton. In vivo it appears as fibrous masses inside bone, with trabeculae of bone and islets of cartilage sprinkled thoughout, capable of expanding to thin or even break the bone cortex. In cranio-facial locations, it is mainly the skull base and maxillary bones which are affected, with swellings creating enormous deformation in severe cases. Radiologically, uncommon lesions of the cranial vault or mandible are depicted as analogous to those of long bones, with well defined bony rare- faction areas, more or less oval, with widening of the bone; but in the maxillae or cranial base, the bone thickens and densifies with more or less advanced obliteration of sinus, nasal, and orbital cavities. This hypertrophy may reach monstrous proportions and resemble Leontiasis ossea. Here are several examples. II-1- Museum specimen n° 382-A. Gross anatomical examination. Two complete maxillary bones horizontally Journal of Paleopathology 19 (1-3) 23sectioned at the level of mid-nasal fossa. These bones are considerably and globally thickened with increased density, more so on the left side, made of porous bone with crushing of sinus cavities almost complete on the left side and partial at the right side. In spite of thickening, this piece appears light in weight. A large osteolytic area is visible on the external side of the left maxilla, with a deep groove joining it to the left nasal fossa. There is no anomaly on the opposite side. The state of preservation is good but with incomplete dental representation: post- mortem missing teeth include the left and right central incisors, left canine, first left premolar and first right molar; ante-mortem missing teeth are the right canine and three left molar teeth. Two other lesions are notable: first, a “tumor” inside the left nasal fossa, very irregular and dense, almost com- pletely filling the nasal fossa and covered with compact bone; for assembly, it has been glued by its lateral, posterior, and inferior sides to the maxillary bone. Size: 30 mm in length, 15 mm in width, and 15 mm in height. Secondly, a posterior “tumor”, regular, almost cylindrical, located in front of the left pterygoid process of the sphenoid bone, at the posterior part of the bony palate, extending obliquely down in an inferior/lateral direction; it measures 28 mm in length, 15 mm in width, and 15 mm in height. (Fig. 2). Figure 2. Maxillae fibrous dysplasia. a- photograph, anterior view. b- radiograph, lateral view, centred on posterior part, c- radiograph, frontal view centred on endonasal sequestrate Radiological examination. Difficult because of the specimen’s morphology and museum assembly, it shows a Journal of Paleopathology 19 (1-3)massive osteocondensation uniformly giving a very dense appearance in every part of the bone. Nevertheless, on the lateral view are seen the posterior “tumor” and, inside, an impacted tooth (dental germ); on the frontal view is observed the high- density opacity inside the left nasal fossa. Medico-historical data. “She was a 62- year-old female who died from cardiac insufficiency. She was entirely d figured by a maxillary disease which had begun about thirty years ago with an osteoperiostitis of dental origin which had become chronic. An extensive protrusion of the maxillary bone body was evident, and her superior lip was too short to cover the inflamed gingival arch. A large moving sequestrate corresponded to the distal superior molar alveoli from which pus continually was pouring out. At autopsy, when this sequestrate was taken out, the remaining bone is described as seeming to be without morbidity but having only a simple generalized hypertrophy of the maxillae” (Maunoir, 1875). Diagnosis. A double pathology seems to exist: on the one hand, an infectious lesion, i.e., maxillary osteitis of dental origin - the “tumor” inside the left nasal fossa is a sequestrate showing the course of the infection (its location is a contrivance for museum presentation), and on the other hand, a fibrous dysplasia of the left maxilla with postero-lateral exostosis, caused by dysplasia proliferation including a wisdom tooth germ. It seems justified to question the relationship between those two diseases: either a dento-maxillary infection over a pre-existent dysplasia, which continued its development during the chronic infectious course, or dysplasia following chronic osteitis. The chronology and asymmetry of the dysplasia favor this last interpretation, but the argument is weak. II-2- Museum n° 383 specimen. Gross anatomical examination. The skull from a elderly adult, with the whole face, mandible, and complete anterior and left middle portion of the cranial base in a very good state of preservation. For the specimen’s pre- sentation, the mandible has been broken at its angle; a repaired post- mortem break at its left horizontal limb is seen, near the chin. In the maxillae, the two central incisors, right canine, and two right premolars are present, with the other teeth lost ante-mortem; in the mandible, only the right two incisors, canine, and two premolars and the left central incisor and canine are present, all of the molars being lost ante- mortem. Considerable thinning is evident on the left side of almost the whole mandible body (right side: 12 mm height vs. 30 mm on the left side, at premolar level), except for the anterior portion containing the incisors, with atrophy Journal of Paleopathology 19 (1-3) 25also of the ascending mandible ramus which is thinned and narrowed (20 mm at angle) in its superior region. Finally, the mandible is lopsided laterally, with the mandibular symphysis situated clearly to the left of the medial line with regard to the maxillae; the head of the mandible is also laterally lopsided, facing the anterior section of the transverse part of the zygomatic process An enormous bony tumor occupies the whole left inferior hemiface, projecting from the medial incisor level of the left maxilla, making a bulky process projecting downward anteriorly and posteriorly, filling the whole oro- pharyngeal cavity and extending beyond the mandible inferior and posterior edges. Size: 95 mm in length (sagittally), 85 mm in height, and 70 mm in width (frontally). Its shape is bilobed, with at left a large convex outside protrusion above the mandible and another posterior protrusion inside the mouth. Its surface is of smooth compact bone, with several slight porous areas and several vascular grooves, especially on the medial surface of the endo-buccal and posterior portions. A sagittal section dividing the posterolateral part reveals its internal structure: very dense spongy bone covered by a thin compact bone cortex (Fig. 3). Radiological examination. A large very dense tumor of the left hemiface, with regular volume, homogenous density, and great size, superimposed Figure 3. Left maxilla fibrous dysplasia, a- photograph, left lateral view (photograph by J-N. Vignal). b- radiograph, anterior view (left side at left). 26 Journal of Paleopathology 19 (1-3)‘on the facial structures and largely obscuring them. Medico historical data. “She was a 65- 70 years old female. An exostosis developed on her left maxilla. Her mouth was continually open. The tumor’s posterior lobe occupied the whole mouth cavity, depressing the tongue and preventing its movements. Chewing was impossible, swallowing difficult, and speech difficult and marred” (Breschet, 1814-15) Diagnosis. We do not know the length of time during which this lesion developed, so we justifiably can hesitate between a fibrous dysplasia of the left maxilla or a bulky spongious osteoma. Nevertheless, its large size pleads on behalf of the first hypothesis, especially compared with prior observation. 11-3- Museum n° 327 specimen. Gross anatomical examination. A whole skull, except for the mandible, from a middle-aged/old female, in a good state of preservation. The vault is vertically poorly developed, especially in the frontal, with the metopic suture present and large wormian bones in the left fronto-parietal suture and posterior part of the sagittal suture. Asymmetric development of braincase is evident, of which the right anterior part extends with a convex curve of the vault to the sagittal suture. The skull cap has been horizontally sectioned in order to see the endocranium. The cranial perimeter is 50 cm long. An enormous oviform tumor, bigger than the skull itself, is established on the right hemiface, extending an- teriorly, inferiorly, and on the left side; the largest circumference is 57 cm and in the perpendicular plan, 44 cm. The skull and tumor together weigh 2 kg The tumor extends posteriorly as far back as the zygomatic fossa and the temporal squama, projecting upward to its mammilary process; it extends downward and to the left to the straight portion of the left zygomatic arch. On the right side it extends from the right frontal and temporal bones, including the zygomatic arch and maxillary bones, the latter being no longer recognizable, as are the nasal, lachrymal and palatine bones. The nasal fossa is replaced by a large cavity which extends as far as the cranial base and leads to the frontal and maxillary sinuses. The dental arch is forced back and to the left, and above all trans- versally crushed, the right and left alveolar processes being separated by no more than 10 mm. On the left, two premolars and one molar remain, and at the right one premolar and one molar. The third molars are absent ante-mortem and all other teeth missing post-mortem. The tumor has, for the most part, a smooth and regular surface, especially at its superior, anterior and left sides; it is more irregular, with nodular parts, posteriorly and inferiorly. It has been sectioned transversally and along its long axis in order to reveal its large Journal of Paleopathology 19 (1-3) 27inner cavity. Its wall is of variably thickened compact bone, from 10 to 30 mm thick, with a very irregular internal side where speckled covered areas alternate with little cavities of 20-30 mm diameter, a perfectly smooth inner surface, and porous or trabecular bone parts (Fig. 4). Radiological examination. The appear- ance of the whole tumor is a large irregular cavity one, dense, hetero- geneous, with variably thickened walls, covered by a very regular and dense cortex. The cavity is irregularly occupied by flecked opacities of variable size. The mass is continuous with the facial bones and sinus cavities. Medico-historical data. “The tumor appeared when she was 4 years old, at the lateral orbital angle, and was hard, bony, as large as a lentil, first attributed to a polyp originating from the right frontal sinus which progress- ively increased in size to compress the superior and medial orbital walls and to completely eject the eye from its cavity. At examination, it was noted that, in the fresh state, the superior part of the tumor was filled by a polyp-like production, born in the frontal sinus, while the inferior part was occupied by a mass of cretaceous matter, impreg- nated with an ichorous and fetid matter” (Houel, 1877). Diagnosis. All features agree with the diagnosis of fibrous dysplasia of the facial bones, with a giant cystic form. II-4- Museum n° 371-A specimen. Gross anatomical examination. The whole skull (except the mandible) of a young child (based on cranial size), in a good state of preservation, but the ante-mortem absence of all maxillary teeth (except the left central incisor and canine eye tooth, lost post- mortem) does not allows a closer estimation of age. Voluminous hypertrophy of the whole right hemiface protrudes in an antero- lateral direction, exclusively affecting the maxilla with projections extending laterally at the level of the zygomatic process, superiorly to the orbital floor and posteriorly to the alveolar process on the left side, deforming slightly the medial portion of the palatine vault and inter-maxillary suture. The surface is, at its superior part, of smooth, compact, regular bone, sprinkled with several slightly porous areas; conversely, the whole inferior part is periostosis-like with a much spongy bone extending to the contiguous part of the left maxillary and nasal bones. The orbital cavity is transversally widened a little but vertically diminished. Its inferior part is perforated, showing that it includes some cavities. Size: 60 mm sagittally, transversely 70 mm, and vertically 65 mm (Fig. 5). Radiological examination. In lateral view is seen radiographically a high- density area occupying the whole inferior part of the face, heterogeneous, 28 Journal of Paleopathology 19 (1-3)Figure 4. Facial fibrous dysplasia. a- photograph, anterior view. b- radiograph, lateral view centred on the tumor. Figure 5. Right maxilla fibrous dysplasia. a- photograph, anterior v ‘adiograph, anterior imposed upon the facial structures that it screens. No trace of the tooth buds is evident. Journal of Paleopathology 19 (1-3)Diagnosis. In spite of the absence of medico-historical data, by comparison with previous examples as guidelines, it is possible, according to the young age of the subject, to diagnose a fibrous dysplasia of the right maxilla. JiI-Osteoma. On dry bone, these bone tumors (mainly constituted of bone tissue) are generally difficult to diagnose only when masked: either endocranially, inside an intact skull or inside a facial sinus cavity. When they develop on the ectocranial surface they are casy to identify either on the cranial vault or on the maxilla, while often disregarded in vivo. Generally sessile, with a wide im- plantation base, osteomas are made of bony tissue, either spongy or ivory- like, always covered by cortical bone; their development is typically quite slow. On dry ancient bone, in frontal endocranial topography they must be distinguished from frontal hyperostosis interna: as our I-I observation (museum n° 370-A) shows, that distinction is not inevitably easy, but osteomas rarely are of bilateral and symmetric topography. In lateral X-rays they appear as a very well-limited bulge of the inner table, and sometimes a transparent edging is visible (with, at gross anatomy, a very thin groove separating it from contiguous cortex) corresponding to the zone of growth. If this groove (or transparent edging) is absent, an osteoplastic response to a meningioma may be represented, but this response often appears irregular and spiky, not smooth, III-1- Museum n? 370-D specimen. For this observation, without medico- historical data, we are satisfied that this specimen shows multiple osteomas of the cranial vault (which had been labelled, at its discovery, as “syphilitic exostoses...”) (Fig. 6). III-2- Museum n° 374 specimen. In the same way, we have no medico- historical data for this specimen but we present it because of its very excep- tional character. Gross anatomical examination. An adult skull cap, of indeterminate sex, horizontally sectioned, including the vertical part of the frontal bone with small parts of the orbital roof and the temporal squamas, both complete parietal bones, and a very small part of the superior occipital squama. The left temporal squama is particularly thin, while the inferior part of the parietal and occipital bones are of normal thickness. The piece was sagittally re- sectioned, slightly to the left of sagittal suture, showing that the left parietal bone thickness is very much enhanced (about 9 mm) with significant thick- ening of the outer table (less so of the inner table) and almost complete obliteration of diploé. There are two voluminous bony tumors. One straddles the two parictal bones just above the lambdoid suture, 30. Journal of Paleopathology 19 (1-3)extending more to the left; it is approximately spherical, extending both externally and internally, and measures 65 mm in length sagittally, 55 mm width transversally, and 55 mm in height. Its surface (both extocranial and endocranial) is very porous, made of compact bone, penetrated by multiple vascular holes; the cross- section shows a very compact tumor, made of very dense bone, with numerous little vascular cavities inside. The other tumor occupies almost the whole height of the frontal bone, and is also more extensive on the left side, against the medial line. Its charac- teristics are identical to those of the first lesion. It begins about 20 mm above glabella and extends back to a point less than 10 mm of coronal suture. Transversally it extends to the left, to within 20 mm of the fronto- temporal suture, near the fronto- parietal suture. On the right side, it extends no more than 30-40 mm from the medial line. It measures 90 mm in height, 80 mm in sagittal length, and 85 mm in width, protruding more inside than outside the skull. Around these two lesions is a periostitic reaction, with porosities and a riddled aspect, particularly extensive on the right parietal bone and less so on the left side and the posterior part of the frontal. Multiples ostcomas of eran a- photograph, ectocranial superior view. b= radiograph, superior view (radiograph by H. Sou Journal of Paleopathology 19 (1-3) 31vory-like osteomas. -xocranial view and cross-section. b- Radiological examination. The frontal tumor (the bigger one) shows a very high density in anterior view; in lateral view it seems heterogeneous, with a dense structure at the centre and trabeculated with several translucent areas at the periphery. The parietal image, smaller and less dense, shows a very trabeculated structure. Both tumors span the cranial vault; the inner table seems intact inside the parietal tumor but the outer one and the diploé seem lost in the mass. In the frontal tumor, denser because it is continuity of the original structures which, nevertheless, scems intact, at least for the inner table. The unaffected free part of the cranial vault, between the two tumors, is very abnormal, with thickening and densification of both inner and outer tables, obliterated diploé and a “hair on end” aspect of the outer table (Fig. 7). Diagnosis. These tumors are frontal and parietal osteomas, peculiar by their considerable development. In regard to the special appearance of the vault between the osteomas: does it indicate 32 Journal of Paleopathology 19 (1-3)that the subject suffered from hemo- globinopathy (thalassemia, for ex- ample)? Medico-historical data are lacking, so we do not know the geographical and ethnic origin of the subject, which might support this argument. We do not know any other example of such an occurrence. IV-Osteochondroma. This non-malig- nant neoplasm, beginning in the bigger, it is difficult to follow the teenage years, is not difficult to diagnose when it occurs at its elective location, the metaphysis of a long bone near the connecting cartilage, and is seen on a subadult or young adult. In dry bone it is reduced to its bony centre, when the cartilage and_peri- chondrium which covered it in vivo have disappeared. It is structurally continuous (in both its compact bone cortex and its spongy central area) with the adjacent normal bone, as clearly seen in X-rays. When this neoplasm appears on an adult bone, it may be located on the diaphysis and have a less typical X-ray appearance: diagnosis then can be more ambiguous, unless we have, as in Campillo’s observation, histological evidence (Campillo, 2005 c). TV-1- Museum n° 392 F specimen. We have no medico-historical data for this specimen, of which we only know that it was from a “young man”; the radiographic images are very typical (Fig. 8). TV-2- Museum n° 392 P specimen. This other example, located on a superior femur, is less evident in dry bone and the medico-historical in- formation is very important. Gross anatomical examination. The superior third of a lefi femur has been obliquely cross-sectioned at head, neck, and superior part of the shaft in a slightly oblique sagittal cut directed upward and laterally. Another section has been made in the subcervical region. Total height: 18 em. A big tumor is visible on the meta- physeal posterior aspect, at the level of the lesser trochanter at the base of the neck, extending back and medially, of irregular morphology. Transversally, it approximates the shape of two hemispheres separated by a depression and is covered by several excres- cences. Size: 80 mm width, 70 mm height, 45 mm sagittal length. Sections show that the tumor is located on top of the bone cortex, rising 50 mm above it; there is neither invasion nor destruction of the cortex, the continuity of which is respected but slightly modified (thickened in the inferior region and thinned superiorly) It is made of trabeculated bone tissue and covered by a cortex of thin compact tissue. It does not commun- icate with the superior part of the medullary canal. Lastly, we must note that preserved musculo-aponeurotic soft tissues are adherent to its surface (Fig. 9). Journal of Paleopathology 19 (1-3) 33Figure 8. Inferior femoral metaphysis osteochondroma, a- photograph, frontal view. b- radiograph, anterior view (radiograph by H. Souris). Radiological examination. A superior femur metaphyseal tumor exhibits a wide implantation base, extending with a pedicle and a bulging extremity. Its structure is trabecular, continuing with- out transition with the metaphyseal bone tissue and surrounded by a thin cortex continuous with the diaphysis and epiphysis. The spongy structure of its implantation base is analogous to normal trabecular tissue; at the pedicle and the bulging extremity, it becomes disorganized, slacker and poorly strue- tured, with trabeculae in all directions separating irregular lacunae. Medico-historical data. “In a 23-year- old man, gradual pain and growth of the left thigh, of which the circum- ference is 9 cm greater than the right thigh. A tumefaction exists in the area of the gluteal muscle, making a regular and uniform protrusion which cannot be displaced nor separated from the femur, of soft consistency and almost painless. At autopsy (the individual died from typhoid fever), a sac located 34 Journal of Paleopathology 19 (1-3)immediately under the gluteus max- imus muscle was discovered, con- taining a sero-sanguineous fluid, without any opening and _ not communicating with the coxo-femoral joint. It covered a large cauliflower- like bony tuberosity, including the small trochanter” (Duguet, 1863). Diagnosis. The metaphyseal topo- graphy, anatomically visible and confirmed radiographically by the continuity of cortex and central spongy Figure 9. Superior femoral metaphysis osteo- chondroma. a- photograph, frontal view. b- radiograph, frontal view tissue with the original bone structure argues for an osteo-chondroma. Moreover, the clinical history, the youth of the subject, and the gradual growth of the tumor are strongly suggestive. V-Bone angioma. This non-malignant neoplasm can be difficult to diagnose in dry bone because of its poly- morphism. There are two essential Journal of Paleopathology 19 (1-3) kinds: cavernous tumors, with wide vascular spaces with very little 35interstitial tissue and showing multiple radio-translucent lacunae; or capillary tumors, where very delicate vessels are separated by plentiful connective tissue with reactive osteogenesis, creating trabeculae inside. The radiological aspect is “grid-like”; vertebrae, the cranial vault, and long bone meta- physes are the elective locations. V-1- Museum n° 380 A specimen. It is an isolated cranial specimen, and the medico-historical data strongly support the diagnosis. Gross anatomical examination. A piece of cranial vault, of which the exact topography is difficult to assess because of its small size (a right temporal, according to the medical history), of approximately quadran- gular morphology, slightly convex a little, measuring 80 x 60 mm. The bony tumor occupies almost the whole piece; it is approximately rounded, strongly thickening the cranial wall to 30 mm. Around the tumor the skull vault is 9 mm thick at its anterior part but only 2 mm at the superior and 4-5 mm at the posterior regions. On the ectocranial side the tumor has an almost regular convex protrusion except at its superior part, where spiculous trabecular appears. On the endocranial side, the aspect is totally covered by radial spikes, which gives a hypervascular aspect (Fig. 10). Radiological examination. This skull vault fragment shows a very hetero- geneous opacity, trabecular with radial Figure 10. Cranial vault haemangioma (temporal). ectocranial view. b- photograph, radiograph, lateral view a- photograph, endocranial view. c~ (radiograph by H. Souris). 36 Journal of Paleopathology 19 (1-3)trabeculae separated by varying-sized transparencies; at lateral view, the jagged outline = and _irregular morphology are evident. Medico-historical datas. “Piece from surgical exeresis, from a 41 years old female, with a tumor which enlarged progressively over 3 years and quickly during the last few months, accompanied by a striking intellectual downfall. Located at the right temporal area, rounded, hemispherical, raising healthy teguments, the size of half an orange, sceming smooth, uniformly hard. The surgical site bled freely, especially during the attempt of decortication from the periosteum. On the other hand, the tumor’s internal part, soft and well delimited, was easily separated from the dura mater which was slightly adherent but not invaded and only pushed inside. After histological examination we concluded that it was a sarcoma in myxoid degeneration” (Morestin, 1899). Diagnosis. We cannot recognize here a sarcoma, neither bony nor of soft tissues with bony invasion: the easy exeresis (except for the periosteal adherence) does not argue for a malignant process, and such a location is extremely rare for an osteosarcoma. On the other hand, the anatomical and the intimate X-rays aspects, the data from the surgical operation, and finally, the good course of recovery undoubtedly argue for a bony haemangioma. VI-Primary malignant bony neoplasms. These are brought together under the generic ~=oname_— of osteosarcomas on dry bone: the exact histological nature cannot be specified otherwise than by — microscopic examination in vivo. Even _ the diagnosis of malignity sometimes is difficult. We present four observations, two of which are, exceptionally, by clinical history, indicated as chondrosarcomas. VI-1- Museum n° 450 & 450A specimen. Gross anatomical examination. An almost complete mandible sectioned in its right and left parts. The right part is longitudinally sectioned, the outer half also having a horizontal cross-section cut along almost its whole length, from the symphysis to 1 cm from the posterior edge of the ascending ramus, at a distance varying between 10 to 18 mm above the inferior edge, below the dental apexes. The left part is also longitudinally sectioned and the two halves are separately presented. The state of preservation is good, except for the medial part containing the incisors and left canine, which are loose. Jn situ are the right three molars, two premolars, and the canine, and on the left, two molars are absent ante- mortem and one molar and the two premolars remain. We observe a tumor covering the two hemi-mandibles. On the left side, it covers almost the Journal of Paleopathology 19 (1-3) 37whole external aspect of the lateral portion as far as the ascending ramus and neck, close to the head of the condyle, mandibular notch, and major part of the mandibular process. It extends down from the inferior edge and upward from the superior margin at the level of the last two (lost) molars, and also anteriorly and poster- iorly from the two edges of the ascending ramus. Its surface is ir- regular and mamillated, with some adherent soft tissues. The cross-section shows the disappearance of the two last molars’ sockets and the very dense and compact structure of this tumor which is adherent to the cortex but does not invade it nor destroy or make it thinner. The inner half is covered by bony radial spikes, with the alveolar margin area overturned and the man- dibular process ahead curved, and the ascending limb seeming to be pushed backwards and medially by a non- osteoplastic part of the tumor which displays a very anarchic structure. The cross-section shows that the horizontal body is partially scraped out. On the right side, the tumor covers the outer side of the whole horizontal body except its posterior part, respecting the angle and the ascending ramus; on the inner side the tumor is slightly elevated on the anterior part of the ascending ramus. It extends downward from the inferior edge, more so at the level of the canine and premolars. Its surface is very irregular, spiky and porous, and inseparable from the cortex (Fig. 11). igure 11. Mandible osteogenetic osteosarcoma. photograph, right opened hemi-mandible. b- radiograph left hemi-mandible, lateral__view raph by H. Souris). c- radiograph right opened hemi-mandible. Radiological examination. In the left hemi-mandible, the radiograph shows a 38 Journal of Paleopathology 19 (1-3)combination of osteolytic and osteo- plastic lesions which entirely alter the bone. The original cortex is visible only at the superior part of the ascending ramus, and is very thin. The rest of the piece is occupied by wide- meshed trabecular bone, with alternat- ing geodic spaces and radiopaque areas, the latter ones particularly located around the mandibular angle and below the first molar. In the right hemi-mandible, the appear- ance is similar but with predominant osteo-condensation, respecting the angle and ascending ramus, and with osteoplastic extensions at the inferior edge of the horizontal body. Medico-historical data. Several reports by the same author (Maisonneuve, 1852, 1853a,b) indicate that “this piece was surgically removed from a 16- year-old female whose left molars began to loosen, six months before, when a tumor appeared at the man- dibular angle and expanded quickly, invading the whole body of the bone on both sides, outer and inner, as far as the level of the incisors near the medial line. The tumor became enormous, with moderate pain but without soft tissue involvement. Nevertheless, the mucosa covering this hard and embossed tumor was purplish-blue with dilated veins, and, near the necks of the teeth, which were deviated and loose, showed ulcers and a fungous aspect, easily bleeding. The operation involved a left half- mandible dislocation with anterior section beyond the medial line between the canine and the lateral incisor. The examination of the affected piece was performed by sectioning parallel to the bone’s axis: we observe a bone softening with production of many cystic cavities containing a fluid including, at microscopic examination, very numerous cancerous cells. After this operation, the young person was apparently well for about one year, then a similar tumor appeared in the left hemi-mandible, of which ablation was performed. The patient recovered very well from this operation but succumbed two years later from the metastasis of the tumor to most of her organs”. Diagnosis. Typical osteogenctic osteo- sarcoma. The malignant character is clinically assessed by the rapidity of initial evolution, the contra-lateral recurrence, and the final metastasis. VI-2- Museum n° 465 A specimen. Gross anatomical examination. The inferior part (around two thirds) of a right femur from an adult subject, with a total height of 27 cm and a moderate state of preservation: superficial altera- tions of the external, anterior, and internal aspects of the cortex of both condyles but preservation of the articular surface. A large tumor surrounding the inferior third of the diaphysis just above the metaphyseal area measures 12 cm in height, 9 cm in antero-posterior diameter, and 6 cm transversally, Journal of Paleopathology 19 (1-3) 39covering all sides of the diaphysis, with greater development on posterior and medial sides. It presents a spiky bony appearance, with radial lamellae perpendicular to the cortex covering the whole surface, with interstices of varying width between them and sey- eral larger spaces, notably two on the medial aspect and another larger one in the middle of the posterior aspect. Because of the way that the specimen is constructed, it is not possible to see the sagittal section through the whole specimen. Several roughened areas of periostosis appear several centimetres superior to the tumor on the posterior-lateral side of the diaphysis (Fig. 12). Radiological examination. \n the lateral view is seen a large tumor surrounding the whole inferior part of the diaphysis and metaphysis with radial and spiky trabeculae. The cortical surface is somewhat irregular but not actually destroyed, but super- position of the tumor obstructs the bony tissue analysis. Medico-historical data. “Spiky osteoid radial needle-like projections, per- pendicularly grafted onto the bone surface: these projections, occupying the inferior third of the femur, are attached to the periosteal surface and are wrapped by sarcomatous tissue. The bone cortical tissue is respected but rarefied, and the medullar space is obstructed by reticular tissue; the vascularisation of the bone’s superior part is enhanced but less so than within the tumor; finally, the condyles are normal” (Houel, 1877). Diagnosis. In dry bone, the appearance is suggestive of an osteogenetic osteo- sarcoma, with a typical topography on the inferior end of the femur. The identification in the fresh bone of a “sarcomatous tissue” confirms this diagnosis, the osteoplastic construction visible in the dry bone being only the central part of this osteogenetic tumor. VI-3- Museum n° 467 specimen. Gross anatomical examination. The inferior half of a left adult femur, measuring 26 cm in height, with the major part being hidden from view by the surrounding tumor and the dia- physis visible only in its superior part; it is slender enough to suggest a female subject, and shows normal cortex on cross-section. For the presentation the piece is vertically sectioned in the sagittal plane and the lateral half alone is presented. This is a very large tumor, measuring 22 em in height and 24 cm sagittally, approximately hemispherical, with a vertical groove, wide and deep, dividing the anterior third from the posterior two-thirds. The surface is irregular and very mamillated, with numerous nodules at the surface and cavil extending deeply into it. The cross-section shows an irregular bony construction, very dense, scattered with cavities of varying size. The articular condyle surface is per- fectly respected and the cortex is 40 Journal of Paleopathology 19 (1-3)Figure 12. Ostéogenetic osteosarcoma of left (photograph by JN. Vi thinned overall at its inferior part; about halfway up it is broken and turned outward inside the tumor mass, on the posterior side. The whole medullar space is occupied by spongy bony tissue, fairly dense but less so than the tumoral tissue itself. The anterior cortex is also thinned, pro- gressively from superior to inferior, and disappears inside the tumor tissue at its inferior part (Fig. 13). Radiological examination. Impossible because of the brittleness of the piece, which makes it too fragile to move. emoral inferior epiphysis. a- photograph, lateral view nal). b- radiograph, lateral view. Medico-historical datas. “Since her earliest years the patient suffered dull pain around the middle of her left thigh, then a tumor appeared which remained stable for some time, then quickly enlarged after she turned 28 years old. There also were bony tumors at the inferior part of her left humerus (anterior face) and right tibia (medial face); but they remained stable during her entire life. Amputation of the left thigh was done when she was 30 years old: the muscles were externally re- flected, the artery was clevated, and the Journal of Paleopathology 19 (1-3) 4nerve was flattened. In the fresh state, this tumor was pearl-coloured, elastic, semitransparent, and the surrounding periosteum thickened, sunk within lobulae, with a mamillated surface. After removing the fibrous wrapper, the tumor had a structure and consist- ency analogous to soft and granulated cartilage. Cavities of the tumor were filled by a cartilaginous substance; at several points it was softened and there were centres tinged with bloody fluid” (Houel, 1877). Diagnosis. As with the previous specimen, we are in the presence of a tumor of the inferior end of a femur. In the dry bone we must note several differences, particularly the rupture of the bone cortex, and the continuity of the tumor with the medullar spongy tissue although its texture is different, probably visible on X-rays; if we had the whole skeleton, we probably could complete the diagnosis. In fact, the clinical history tells us of the previous existence in situ of a “steady state tumor” and of other tumors on other bones, the left humerus and right tibia, so multiple exostoses were present. Moreover, pathological examination of the operative piece shows its cartilaginous structure. Finally, the accelerated growth that justified its amputation evokes a secondary malig- nant degeneration. So, we conclude that it was a chondro- sarcoma by degeneration of an osteo- chondroma, with multiple exostoses. VI-4- Museum n° 426 A specimen. It illustrates an analogous problem. Gross anatomical examination. This specimen consists of the inferior third of a left tibia and fibula, with the talus, and a large tumor separated from its primary bones by a sagittal section. The total height of the piece is 14 cm. The bone has a youthful aspect, with a good state of preservation. The large tumor is located on the antero-lateral side of the tibia and fibula; size: 85 mm in height, 50 mm transversally, and 10 mm sagittally. Its implantation base is irregular. The tibio-tarsal and fibulo-tibial joints are normal; but the fibular inferior end is strongly distorted by the tumor, whose implantation base is 70 mm high on the fibula but only 50 mm on the tibia. The fibula cortex has a deep groove, 4 mm wide, along the superior edge of the implantation base. The tumor is very irregular, roughly pyramidal, and very nodular and budded, like a cauliflower. The cross section shows a structure with alternating compact bones, porous bone, and micro-cavities. Radiological examination. A large bony construction is presented as apart from the bony group (tibia-fibula- talus). Its shape is very irregular with an irregular edge, open at the major part of the circumference, except for the inferior margin, bordered with a thin cortex. Its structure is very heterogeneous, with alternating areas of fairly dense trabecular bone and numerous translucent cavities of varying sizes (Fig. 14). 42 Journal of Paleopathology 19 (1-3)‘emoral second: Journal of Paleopathology 19 (1~Figure 14. Fibula. secondary _chondrosarcoma. view (photograph by J.-N. Vignal). b- radi Medico-historical data. “Piece obtain- ed after amputation, from a c. 30-ye: old man. The tumor appeared when he was 16 years old, some 14 years ago. Its location is on the inferior end of the fibula which does not fuse before 16 years of age. Primarily, this exostosis was located on the external malleolus and remained stable for a long time. Two years before the surgical opera- tion, it quickly progressed, ulcerated the skin, and amputation was decided a- photograph, aph, lateral view (radi bones cross sectioned, lateral raph by H. Souris). upon when it invaded the tibia” (Broca, 1866), Diagnosis. The gross anatomical aspect in dry bone is here less suggestive because the cortex rupture and continuity of the tumor with the spongy bone tissue are not observed. But the clinical history informs us that a lateral malleolus exostosis existed since the subject was 16 years old, which suggests an osteochondroma. That exostosis increased quickly after 44 Journal of Paleopathology 19 (1-3)12 years of development and justified amputation two years later. So, we conclude that it was a chondro- sarcoma secondary to malignant degeneration of an isolated osteo- chondroma located at the external malleolus with extension to the tibia. Conclusion. After this presentation of several muscum specimens, most of them clinically documented (and we could present many others, given the full range of treasures in the Dupuytren museum), it clearly seems that medico- historical data permit a much more secure diagnosis than would be possible for a field or laboratory osteoarchaelogist with only gros anatomical and radiological informa- tion available. That is why we think that this process of establishing well- evaluated image guidelines is useful in palacopathology. It constitutes, more- over, a defence in favour of protecting and rationally utilizing the documented skeletal specimen collections in the large pathological museums in the world, which are, alas! often threat- ened. Acknowledgments. We are obliged to Dr JY Glon for the major portion of the radiological examinations, and to Major H Souris for the remaining radiographic images. Mr J N Vignal kindly provided several photographs, and Pr R Abelanet granted us permission to examine these specimens from the Dupuyiren muscum. To all of them, we express our sincere gratitude. References. Abelanct R 1990 Les Musées d’Anatomic Patho- logique de Paris. Le Musée Dupuytren In La Médecine a Paris du XIlle au XXe siécle Paris Havas Ed p 2 Abelanet R & De Saint Maur PP 1991 Le Musée Dupuytren, passé et présent Histoire des Sciences Médicales 25 p 127-131 Abelanet R 1993 Centre Universitaire des Cordeliers. Queiques lignes pour un passant Arch. Anat . Cytol. Path Al 2: p 89-98. Aufderheide AC & Rodriguez Martin C 1998 The Cambridge Encyclopedia of Human Palaeo- pathology Cambridge New York Melbourne Cambridge University Press p 468. Breschet_ M_ 1814-15 Description d'une tumeur osseuse considérable développée a la face Bullerin de la Faculté de Médecine de Paris 4 : p 332-335. Broca PP 1866 Exostose cartilagincuse de Vextrémité inférieure du péroné Bulletin de la Société Impériale de Chirurgie de Paris 2 série 7 p 295-297. Brothwell A D & Sandison A T 1967 Diseases in Antiquity: A survey of diseases, injury and surgery of earlier populations Springfield Illinois ‘Thomas C p 766. Campillo D_ 2005 Paleoradiology. 1. Anatomical variability Journal of Paleopathology vol 17 0 1p 11-26 Edigrafital Teramo (Italy). Campillo D 2005 b Paleoradiology. 11. Congenital and hereditary malformations of the skeleton Journal of Pateopathology vol 17 n 2 p 45-64 Edigrafital Teramo Italy. Campillo D 2005 ¢ Paleoradiology. Ill. Neoplastic conditions Journal of Paleopathology vol 17 3 p 93-136 Edigrafital Teramo Italy. Charon P 1996 Catalogue ostéo-archéologique des collections anatomiques du Musée Dupuytren Paris, Proposition et illustration. Les exostoses Mémoire du diplome de I’Ecole Pratique des Hautes Etudes Paris p 168 atlas photographique et radiographique. Journal of Paleopathology 19 (1-3) 45Charon P 2008 Le diagnostic rétrospectif en ostéoarehéologie in: Osteo-archéologie et techniques médico-Iégales: tendances et perspectives. Pour un “Manuel pratique de palgopathologie humaine” Paris, De Boccard p 684. Dastugue J & Gervais V 1992 Paléopathologie du squelette humain Paris Boubée éd 253 p 94. Denonvilliers C & Lacroix P ACROIX 1842 ‘Muséum d’Anatomie Pathologique de la Faculté de Médecine de Paris, ou Musée Dupuyiren Paris Béchet jeune et Labé libraires de la Faculté 2 tomes et Atlas. De Seze § & Ryckewaert A 1972 Maladies des os et des articulations Paris Ed, Médicales Flammarion p 1242, Duguet M 1863 Ostéophyte du petit trochanter du fémur avec une bourse séreuse accidentelle Bulletin de la Société Anatomique de Paris 2 séric 8: p S47- 548. Houel C 1877 Catalogue des piéces du Musée Dupuytren Paris Dupont P & Masson G Ed. Maisonneuve J G 1852 Présentation de toute une portion latérale du maxillaire inférieur affecté de cancer Bulletin de la Société de Chirurgie de Paris 2:p221-225. Maisonneuve J G 1853a Désarticulation de la moitié latérale gauche de la machoire inféricure Bulletin de T'Académie de Médecine \7 : p 909-912. Maisonneuve JG 18536 Ablation de 1a machoire inférieure pour un cancer de cet os Guérison Gazette des Hopitaux 53 : p 218. Maunoir L 1875 Ostéite condensante du maxillaire inférieur Bulletin de la Société d'Anatomie de Paris 10 : p 558-559. Morestin H_ 1899 Tumeur du erine comprimant le cerveau et déterminant des crises épileptiformes : extirpation par une large résection cranienne ; guérison Bulletin et Mémoires de la Société Anatomique de Paris 1: p 249-252. Ortner D J & Putschar WG 1981 Identification of Paleopathological conditions in Human Skeletal Remains Smithsonian Institution Press Washington and London. Thillaud PL 1992 a Retrospective diagnosis. in Paleopathology: osteological syndrome and elementary lesions on ancient bones Paleopathology Newsletter 80 Thillaud P L 1992 b Le diagnostic ostéo- archéologique in: Maladie et malades: histoire ot coneeptualisation; mélanges en ’honneur de Mirko Grmek Geneve Droz p 13-30. Thillaud PL & Charon P 1994 Lésions ostéo- archéologiques. Recueil et identification Sceaux Kronos B.Y. €d. p79. Thillaud P L 1996 Traité de Paléopathologie Humaine Kronos BY Ed Sceaux p 238. Ubelaker D H 1978-1989 Human skeletal remains. Excavation, analysis, interpretation Washington Maxacum Smithsonian Institution Press p 172. Wells C Bones, bodies and disease: evidence of disease and abnormality in early Man, London Thames é& Hudson p 288. 46 Journal of Paleopathology 19 (1-3)J.o.P. 19 (1-3) 2007: 47-56 AN EXCESSIVE OSSIFICATION OF COSTAL CARTILAGE LINKED TO A TRAUMATIC PATHOLOGY Y. Gleize* D. Castex* H. Duday* Abstract. A skeleton from the medieval graveyard of Clarensac (Gard, France) presents an excessive ossification of the costal cartilage in the lower thorax. This type of ossification is usually associated with senescence. The left ribs of the same individual showed several healed fractures. Because of their respective positions, a direct link between the ossification of the costal cartilage and the fractures is suspected: the ossification resulted from hemorrhaging following soft tissue trauma caused by the rib fractures. Introduction, pathologies (Dutour, 1986; Palfi & In archaeological excavations, bones and teeth are often the only human remains found. The conser- vation of other bodily parts is usually due to particular environmental conditions seldom found in temperate surroundings (Janaway, 1997). Some parts of the body such as ligaments and tendons, which normally decompose rapidly after death, can ossify during the lifetime of the individual. These ossifications, called enthesophytes or osteophytes, can be caused by degenerative processes or by certain Dutour, 1996). The hyaline cartilage, such as that found in the costal cartilages, may also mineralise during an individual’s lifetime (Baud & Kramar, 1990). These ossifications are extremely variable, ranging from small bony areas to complete ossification (Stewart & McCormick, 1984). Although a few cases have been recorded in archeological contexts (Thillaud, 1995; McCormick & al., 1985), they often go unnoticed because of their fragility or are simply unrecognised (Scheuer, 2002). “Laboratoire d'Anthropologie des Populations du Passé. Université Bordeaux: 1. Avenue des Facultés, 33405 Talence Cedex. France.Ossified costal cartilage has frequently been described as a potential tool in the estimation of age-at-death (Stewart & McCormick, 1984; Kunos et al., 1999). Methods of age estimation based on observation of the remodelling of the sternal end of the fourth rib provide informative results (Iscan & Loth, 1986a,b), but it is nevertheless debatable that the ossification of costal cartilage can be considered an indication of exact age-at-death in anthropology or forensic medicine (Barchilon et al., 1996; Schmitt & Murail, 2002). An unusual example of ossification of the costal cartilage is presented here, with a detailed description and discussion of its etiology, which can probably be linked to pathology of the thorax rather than to the age at death of the individual. Archeological context and method of analysis. The subject examined is one of fifteen individuals from the site of Clarensac (Gard, France,10""-14"" century, according to the typochrono- logy of the tombs). The site was partially excavated in 1996 during a salvage operation (Boyer, 2000) and benefited from an archeo-anthropo- logical analysis that aimed at specifying the modes of burial and the biological characteristics of this small sample Gleize, 2002). The meticulous cleaning of the osscous remains allowed the identification of several pathological lesions affecting the ribs of one individual, but also revealed the presence of some unusual ossified structures. Although the skeletons had been damaged by bulldozers when the site was discovered (Fig. 1), a simple macroscopic observation allowed the restoration of complete ribs and an evaluation of their respective positions. These fragments were also X-rayed. An estimation of biological character- istics, such as age and sex, of the individual concerned was then attempted. ¥e Ge EE Ek of ch Figure 1. Diagram of preservation of the skeleton (the bones in grey) with the position of the callus formations marked (black). 48 Journal of Paleopathology 19 (1-3)In view of the methodological uncertainty surrounding the age estimation of adults (Masset, 1990, 1993; Schmitt, 2001 and, more recently, Bruzek & al., 2005) two methods were preferred. The first observes the osseous maturation of the sternal end of the clavicle: the absence of fusion suggests an age-at-death under 30 (Owings-Webb & Suchey, 1985; Kreitner & al., 1998). In the case of complete fusion, the second method, a visual approach proposed by Schmitt (2001, 2005), using the auricular surface of the ilium (Schmitt & Broqua, 2000), was employed. Sex determination employed a visual procedure (Bruzck, 2002) and a morphometric analysis of the pelvis that leads to a probabilistic sex diagnosis (Murail & al., 2000). The rest of the skeleton was examined in order to find any other ossification which might show _ pathological processes linked to senescence. A comparative study of the other individuals from the site was also undertaken. Description of the individual. The individual is a male (95% probability) adult. The iliac crest and the sternal end of the clavicle are completely fused, and the morpho- logical characteristics of the auricular surface suggest an age estimation of between 30 and 59 years (93% probability); although wide, this interval does reliably eliminate an individual of over 60. A number of other observations help to clarify this assessment, including the radiological observation of the trabecular structure of the femoral heads (Ferembach & al., 1980), the general condition of the dentition and the absence of arthrosis- like lesions, suggest an age closer to 30 than to 59. Among the osseous remains, about 15 ossified fragments were found. These brownish fragments were hard, flat, and curved with a fibrous outer appearance and an average length of 10cm. (Fig. 2). Some of them could be joined by pscudoarthroses, but others were still attached to the sternal ends of the ribs and proved to be ossifications of the costal cartilages. Figure 2. Example of ossified costal cartilage The term ‘ossification’ seems more appropriate than ‘calcification’. A number of authors have already drawn attention to errors in the terminology Journal of Paleopathology 19 (1-3) 49relating to costal cartilage (Semine & Damon, 1975; King, 1939), and the necessity of differentiating between calcification and ossification. Calci- fication corresponds to a biological deposit of calcium salts onto connective tissue, whereas ossification corresponds to a more complex procedure which, during its formation, is characterised by a regular, irrigated, and trabecular texture (Baud & Kramar, 1990, 1991). Nevertheless, calcification tends to become ossification as, for example, in the formation of pleural plaques (Baud & Kramar, 1991). In the absence of precise on-site data to provide paleopathological informa- tion useful in diagnosis (Duday, 2005), a reconstruction of the ribs was attempted, so as to locate the anatomical position of the ossified cartilages (Fig. 3). Their size and the contact surfaces place them in the lower thorax, probably starting at the sixth rib. X-ray analysis shows a certain homogeneity (Fig. 4). Taking the typology of McCormick & al. (1985) as a reference, these ossifica- tions are most like those of class E, which is found chiefly in older men (McCormick & Stewart, 1983). One wonders if this individual had respiratory difficulties. The absence of similar ossification on the vertebrae and the discovery of articular surfaces at the sternal end of the ossified cartilages could have compensated for Figure 3. Ossified fragments of skeleton. Attempted reconstruction, Figure 4. X-ray of ossitied co cartilage the loss of elasticity in the cartilages without producing microfractures. 50 Journal of Paleopathology 19 (1-3)Figure ribs, Presence of callus formations on the left Figure 6. X-ray of rib fractures. No other instance of degenerative ossification, such as the presence of osteophytes in the vertebrae or remodelling of enthuses, was revealed by macroscopic observation. However, the reconstruction of the ribs revealed traumatic lesions. At least five callus formations, of which two were con- nected (Fig. 5), were observed among the fragments of the left ribs on the endothoracic surface. These callus formations are hypervascularised, 2-4 em long and 3 em wide at their thickest point. They attest to healed fractures of the ribs. Macroscopic and radiologic obser- vation (Fig. 6) revealed that, systematically, the two fragments resulting from the fractures have overlapped after a transverse displacement. All of the fragments belonging to the left side and each of the two entirely ssembled ribs possess callus formations placed one above the other. The zones in which the fractures are found are similar in width and shape and two of the callus formations are joined together, one above the other. The observation of the two completely reconstructed ribs, each with a callus formation and an ossification of the costal cartilage, suggests that the fractures were situated on the left side of the thorax, probably between the fifth and ninth ribs, and that they were caused by blunt force trauma directed from the side. All of the callus formations being in the same zone, we can observe a line of fractures which seems to indicate multiple and simultaneous lesions of several left ribs leading to the formation of a flail chest (Fig. 1). The union of two ribs by a thin band of bone may be interpretated as resulting Journal of Paleopathology 19 (1-3) SIfrom the ossification of a hemorrhage following a fracture (Rogers & Waldron, 2001). The sternum being badly preserved, it was impossible to verify whether or not this structure had suffered trauma (Fig. 1). No other example of excessive ossification or callus formations around the ribs was found after examination of the other individuals from the site: the observations made on this individual are unique in this archeological sample Discussion. The almost total ossification of the costal cartilage in the lower part of the thorax of an individual would seem to indicate a peculiar biological process The costal cartilage seems to be one of the few points where endochondral ossification continues in adults (Semine & Damon, 1975). Several articles have confirmed the frequent relationship between the ossification of costal cartilage and the advanced age of the subject, the most important cases concerning individuals of over 50 years (Semine & Damon, 1975; Stewart & McCormick, 1984; Barchilon & al., 1996). In this case it seems unlikely that the process of senescence was involved because of this individual’s relatively youthful age-at-death. Several hypotheses have been expressed to explain the ossification of the costal cartilage. Whether concern- ing the first rib in young pilots (Barchilon & al., 1996) or the lower thorax in older persons (Semine & Damon, 1975), studies show that biomechanical strain on the ribs increases the ossification of the cartilage. However, the absence of other evidence of microtrauma (e.g. arthrosis, enthesophytes) on the skeleton studied renders the application of these aetiologies to explain the observed changes in this individual unlikely. Physiological differences as well as different dietary habits can explain the variations recorded when the preval- ence of the ossification of costal cartilage among certain populations is calculated (Semine & Damon, 1975) In the present archeological sample, although the number of adults is small, no other individual shows an ossifica- tion of the costal cartilage. The absence of other pathological ossifications or calcifications on the skeleton also rules out, at least partially, any anomaly related to calcium metabolism or hypercalcemia (Cotran & al., 1999). Other research has shown, in fact, that there is no connection between this type of ossification and specific illnesses (Barchilon & al., 1996). Nevertheless, although no real difference exists between individuals suffering from osteoporosis and those unaffected by such a condition, Vieira & al. (1966) reported a lower proportion of ossified cartilage in individuals suffering from osteomalacia. 52 Journal of Paleopathology 19 (1-3)Some authors also consider a genetic predisposition (Vastine & Vastine, 1946 cited by Scheuer & Black, 2000), although this has never really been demonstrated. The absence of other ossifications or degenerative phenomena on the skeleton examined does not allow the ossification of the cartilage to be linked to a systemic pathology. Accordingly, the only notable characteristic observed on_ this individual remains the callus forma- tions, previously described, in the lower left-hand thorax, — which correspond to healed fractures. Because of their position in the same anatomical area, the hypothesis of a relation between this traumatic pathology and the excessive ossifica- tion of the costal cartilage can be considered. The possibility of an ossification of the cartilage following a traumatic episode needs to be examined. Although unsuspected, cartilage fractures are associated, in numerous cases, with those of the ribs (Kara & al., 2003; Malghem & al., 2001). Although difficult to observe radiographically, they can be ascertained by the present of a few islands of ossification (Battistelli & Anselem, 1993; Fukuda, 1988; Malghem & al., 2001; Ontell & al., 1997). Different biological processes thus allow the transformation of cartilage into bone during the repair of a fracture (Nakase & al., 1998). However the radiographs and macroscopic observations made on the subject under study show no specific area of ossification but a general ossification of the cartilage. The costal cartilage can also be affected by other types of pathology, such as a suppurative infection of the costal cartilage, following the necrosis of the cartilage after trauma, or ischemia (Scheuer & Black, 2000; Elson, 1965). As the ossification between two ribs would suggest, multiple simultaneous traumatic lesions probably caused bleeding following the laceration of certain tissues (Rogers & Waldron, 2001), which could thus have facilitated an ossification of the cartilage. Recent articles on the impact of blood on the hyaline cartilage, particularly articular, support this hypothesis (Hooiveld & al., 2003; Roosendaal, 1999). in vitro and in vivo experiments have shown that bleeding onto cartilage, as in a hemorrhage, can facilitate the apoptosis of the chondrocytes, more so in younger adults. Following the death of the cartilaginous cells, an intracellular calcification tends to occur (Cotran & al., 1999). Other microbiological work has shown that the “chondrocyte- derived apoptic bodies” possess functional properties which tend to facilitate the deposition of minerals in the matrix, ie., a pathological calci- fication of the cartilage (Hashimoto & al., 1998), that explains certain ageing processes. After trauma, necrosed Journal of Paleopathology 19 (1-3) 53cartilaginous tissues can thus undergo dysplasic calcification (Cotran & al., 1999). As in the normal mechanism of ossification, the calcified chondrocytes are then destroyed by osteoclasts, and osteoblasts stimulate bone formation. The deterioration of the cartilage, brought about by haemorrhaging, could thus be followed by ossification of cartilage. It would seem possible, therefore, to suppose, that a violent blow to the left side of the individual caused the fracture of several ribs and, consequently, the laceration of certain tissues, causing a hemorrhage. This bleeding then caused an alteration of the costal cartilage with post-traumatic ossification. Conclusion. The medieval skeleton with clear traces of an excessive ossification of the costal cartilage proved to be a particularly interesting case-study. Both the absence of other degenerative pathologies on the skeleton and the age-at-death estimate for this individual ruled out an etiology often connected with the physiological processes of senescence. The presence of multiple fractures in the lower thorax is evidence of a violent blow to the left side of the individual. This injury produced internal haemorrhaging that also damaged the costal cartilages, causing them to ossify prematurely. This impressive phenomenon could there- fore be the secondary consequence of a traumatic accident. This example demonstrates that the ossification of costal cartilage, which is variable from one individual to another, can also be influenced by pathology and cannot in all cases be considered as a definitive estimator of age-at-death. Acknowledgements. ‘We would like to express our gratitude to O. Boyer, CC. Kramar, and M. Bessou for the X-ray analysis and to the members of the LAPP UMR 5199 PACEA. Also, we thank Frances Holden for help with translation and to Christopher Kniisel for his ‘comments, References. Barchilon V_ Hershkovitz I Rothschild B Wish- Baratz S Latimer B Jellema L Hallel T & Arensburg. B 1996 Factors affecting the rate and pattem of first costal cartilage ossification Am J Forens Med Path 17: 239-247, Battistelli J. M & Anselem B 1993 Apport de Véchographie dans les traumatismes des cartilages costaux J Radiol 74: 409-412. Baud C A & Kramar C 1990 Les calcifications biologiques en archéologie Bulletins et Mémoires de Ja Société d’Anthropologie de Paris 2: 163-170. Baud CA & Kramar C 1991 Soft tissue caleifications In Human Paleopathology Current ‘Syntheses and Future Options Ortner D Aufderheide A eds Smithsonian Washington D.C. 279-290. Boyer © 2000 Fouille de sauvetage du cimetiore médiéval de Clarensac (Gard) Rapport de fouille SRA Languedoc Roussillon. Bruzek J 2002 A method for visual determination of sex using the human hip bone American Journal of Physical Anthropology \17: 157-168 DOL 10 1002/ajpa 10012. 34 Journal of Paleopathology 19 (1-3)Bruzek J Schmitt A & Murail P 2005 Identification biologique individuelle en _paléoanthropologie Détermination du sexe et estimation de lage au décds A partir du squelette In Objets et méthodes en paléoarthropologie Dutour QO Hublin JJ Vandermeersch B eds CTHS Paris 217-246. Cotran R Kumar V & Robbins $ 1999 Robbin’s Pathologic Basis of Disease WB Saunders Philadephia. Duday H 2005 L*archéothanatologie ou archéologie de la mort In Objes ei méthodes en paléoanthropologie Dutour OQ Hublin JI Vandermeersch B eds CTHS Paris 153-216. Dutour © 1986 Enthesopathies (lesions of muscular insertions) as indicators of the activities of Neolithic Saharian populations American Journal of Physical Anthropology 71: 221-224. Elson R A 1965 Costal chondrit and Joint Surgery 47: 155-160. Journal of Bone Ferembach D Schwidetzky I & Stloukal M 1980 Recommendations for age and sex diagnoses of skeletons. Journal of Human Evolution 9: 517-549. Fukuda $ 1988 Calcification and fracture of costal cartilage in beagles. Nippon Juigaku Zasshi 50 1009-1016. Gleize Y 2002 Le cimetiére médiéval de Clarensae (Gard) étude anthropologique et _pratiques funéraires Mémoire de DEA en Anthropologie Biologique Université Bordeaux 1 Hooiveld MJ J Roosendaal G Vianen ME Marijke yan den Berg H Bijlsma J W & Lafeber F PJ G 2003 Immature articular cartilage is more susceptible to blood-induced damage than mature articular cartilage An in vivo animal study Arthritis and rheumatism 48: 396-403 DOL 10 1002/art 10769. Hashimoto S Ochs R L Rosen F Quach J McCabe G Solan J Seegmiller J E Terkeltaub R & Lotz M 1998 Chondrocyte-derived apoptotic bodies and calcification of articular cartilage Proc. Natl Acad Sci 95: 3094-3099. Iscan M Y & Loth SR 1986a Determination of age from the stemal rib in white males a test of the phase method Journal of Forensic Science 31: 122- 132, Janaway RC 1997 The decay of buried human remains and their associated materials In Studies in crime An introduction 10 forensic archaeology Hunter J Heron C Knupfer G Martin A Pollard M Roberts C eds Routledge London 58-85. Kara M Dikmen E Erdal HH Simsir 1 & Kara $ A 2003 Disclosure of unnoticed rib fractures with the use of ultrasonography in minor blunt chest trauma European Journal of Cardio-thoracic Surgery 24: 608-613. King J B 1939 Calcification of the costal cartilages Br J Radiol 12: 2-12. Kreitner K F Schweden N P Riepert T Nave B & Thelen M 1998 Bone age determination based on the study of the medial extremity of the clavicle. Musculoskeletal Radiology 8: V1 6-112. 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Journal of Paleopathology 19 (1-3)Murail P Bruzek J & Houet F 2000 Stability of the human pelvic sexual dimorphism pattern allows probabilistic sex diagnosis among Homo sapiens sapiens Abstracts of the 12th Congress of the European Anthropological Association Cambrideg England 8-[ 1 September 55-56. Nakase T Sugimoto M Sato M Kaneko M Tomita T Sugamoto K Nomura $ Kitamura Y Yoshikawa H Yasui N Yonenobu K & Ochi T 1998 Switch of osteonectin and osteopontin mRNA. expression in the process of cartilage-to-bone transition during fracture repair Acia Histochemica 100: 287-295. Ontell F K Moore E H Shepard J A O & Shelton D K 1997 The costal cartilages in health and disease Radiographics 17: $71-577. Owings-Webb P A & Suchey J M 1985 Epiphyscal union of the anterior iliac crest and medial claviele in a modern multiracial sample of american males and females American Journal of Physical Anthropology 68: 457-466. Palfi G & Dutour O 1996 Les marqueurs d’activité sur le squelette humain Aspects théoriques et application 4 des séries _ostéoarchéologiques européennes In Lidentité des populations archéologiques. Actes des 16° — rencontres internationales d’archéologie et _ d'histoire d’Antibes APDCA: Sophia Antipolis 245-269. Rogers J & Waldron T 2001 DISH and monastic way of life International Journal of Osteo- archaeology 11: 357-365 DOI 10 1002/0a 374. Roosendaal G Vianen M E Marx J J M Marijke van den Berg H Lafeber F PJ G & Bijlsma W 1999 Blood-induced joint damage A human in vitro study Arthritis and rheumatism 42: 1025-1032. Scheuer L 2002 Application of osteology to forensic medicine Clinical anatomy 15: 297-312 DOI: 10.1002/ca.10028. Scheuer L & Black $ 2000 Developmental juvenile osteology Academic Press: London Schmitt A 2001 Variabilité de ta sénescence du squelette humain, Réflexions sur les indicateurs de Vage au décés. dla recherche d'un outil performant These de dociorat Université Bordeaux 1. Schmitt A 2005 Une nouvelle méthode pour estimer Page au décis des adultes A partir de la surface sacro-pelvienne iliaque Bulletin et Mémoires de la Société d'Anthropologie de Paris \7 : 89-101. Schmitt A & Broqua C 2001 Approche probabiliste pour estimer age au décés a partir de la surface auriculaire de Vilium Bulletin et Mémoires de la Société d'Anthropologie de Paris \2: 279-301 unitt A & Murail P 2002 Is the first rib a reliable indicator of age at death assessment? Test of the method developed by Kunos & al 1999 Homo 54: 207-214, Semine A A & Damon A 1975 Costochondral ossification and aging in five populations. Human Biology 47: 101-116. Stewart J H_& McCormick W F 1984 A sex- and age-limited ossification pattern in human costal cartilages. American Journal of Clinical Pathology 81: 165-769. Thillaud PL. Kronos Paris. 1995 Traité de paléopathologie Vieira C E Kahn M F Ryckewaert A & Séze (de) S 1966 Fréquences comparées de_ T'ostéophytose lombaite, des calcifications des cartilages costaux et des calcifications de 'aorte abdominale chez les sujets atteints dostéoporose ou d’ostéomalacie ct chez les sujets témoins La Semaine des Hopitau 42; 2513-2517. 56 Journal of Paleopathology 19 (1-3)J.o.P. 19 (1-3) 2007: 57-61 A CASE OF BIPARTITE PATELLA IN A PALEOCHRISTIAN NECROPOLIS IN MARSALA (ITALY) A. Messina* L. Sineo* Abstract. (2) This report describes one case of bipartite patella in an adult male recovered from a Palaeochristian lay cemetery (II-IV centuries a.C. in Marsala (Sit Italy). Bipartite patella is a pathological condition rarely described in archaeological contexts, although it is a very well known lesion in orthopaedic and radiographic studies. The disease seems to be more common in males, and there is no clear relationship with developmental and morpho-functional issues. This case report adds new data to the sparse literature on this pathological trait. Introduction, The incomplete ossification of one bone of the knee joint, the patella, known clinically as bipartite patella (patella partita), is a rare finding in archaeology, and not a very frequently described subject in palaeopathological bibliographies. The first description of this condition in a medical context, discovered at autopsy, was made by Gruber (1883). Since this report, additional cases have been described in the medical literature (Wright, 1904; Saupe, 1921; Adams & Leonard, 1925; Pass, 1931; Blumeensaat, 1932; George, 1935; Stuke, 1950; Shulman, 1955, Resnick & Niwayama, 1981; Tachdjian, 1990; Silverman & Kuhn, 1993; Duthie & Bentley, 1996), and also in the osteological and anthropological literature (Finnegan, 1978; Mann & Murphy, 1990; Scapinelli & Capasso, 2000; Scheuer & Black, 2000; Anderson, 2002). Saupe (1921) classified bipartite patella in three different types, based on the position of the accessory ossification centre. Type I (5%) involves the apex of the bone; type II *Laboratorio di Antropologia, Dipartimento di Biologia animale “G. Riverberi”, Palermo, ttaly.(20%) involves the lateral side of the patella and has a_ longitudinal expression; and type III (75%) involves the lateral crest. Different authors indicate a predom- inance of this condition in males, with a prevalence ranging from 70% to 90-100% (D’Alb & al, 1962; Blumeensaat, 1932). According to Green (1975) the bilateralism of the condition is rather common (43%). Messeri (1958, 1961) suggest that “this high frequency was due to the continuous tension of the vastus lateralis of the femoral quadriceps associated with squatting”. The incomplete ossification of the left patella was discovered in an adult individual found in Marsala (Trapani, Sicily, Italy), in September 2004, during the excavation of the Necropolis of San Giovanni, at the “Parco Archcologico” of the town. On the basis of different lines of evidence, the site has been described as a lay cemetery of the Palaeocristian Period, and chronologically ascribed to the III- IV cenuries a.C. The Necropolis is not very large; several skeleton remains, representing a minimum number of 30 individuals on the base of standard criteria (Marella, 2003) were recovered. The case report. The object of the report was found in an ossuary containing four different adults, overlying one after the other. A meticulous excavation and laboratory reconstruction, allowed the attribution of this patella to the individual “O1”, identified as male on the base of anthropometrical and anthropological traits (Bruzek, 2004; Murail & al, 2005). The other three individuals have been identified as females. On the base of the dental damage and wear (Miles, 1963; Meindl & Lovejoy 1985) the age at death of this individual was estimated at approx- imately 40 years. “Specimen O1” consists of the calvarium, the mandible, a well preserved pelvis, a complete right upper limb, and a very fragmented left upper limb; the lower limbs include only the complete femurs and tibias. ‘An asymmetry in the stress indicators on the right upper limb is clearly visible: the humerus presents a very well developed tuberositas deltoidea, the ulna is characterised by a enthesopathy at the level of the pronator and pronator quadratus, and the radius has a large enthesopathy at the insertion of the distal portion of the biceps. No particular indications of asymmetry or muscular-related bone stresses are evident in the lower limbs. The patella from the left leg shows a lack of ossification of the lateral side (Figs. 1 and 2), where the bone is porous and the surface is rough-edged (Fig. 3). The specimen is lacking the normal lateral portion of the bone. On the basis of these indicators, according. to Saupe (1921), the pathology can be diagnosed as Patella partita type Il. 58 Journal of Paleopathology 19 (1-3)Figure 1. The left patella of a 40-41 year old male (Specimen O1) displaying a ‘fracture I ing through the supero-lateral apex. Figure 2. The different pattems of ossification in the patella (modified from Anderson 2002). The right patella is badly damaged and not available for a diagnosis or for comparative analysis. Clinics, Diagnostics, and literature data on Patella Partita. This pathology, well known in the orthopaedic literature mainly through fortuitous radiological diagnosis 2 Figure 3. Sicreomicroscopic view of the surface of the super-lateral ridge of the left patella. Note the deficit in ossification (Resnick & Niwayama, 1981; Scapi- nelli & Capasso, 2000) is normally described as a rarely symptomatic congenital condition. Patella partita can erroneously be attributed to a fracture related to a traumatic event (Anderson, 2002). It is generally characterised by one or more vertical discontinuities in the different centres of ossification of the bone (Soren & Waugh, 1994). Additional ossification centres may become apparent in the adolescent period, the most common being the supero-lateral border location, where the margin remains irregular (Baker & al., 2005). During development it may then fuse with the main centre of ossification or remain separated from it, and form a bipartite patella, with the two parts Journal of Paleopathology 19 (1-3) 59being joined by fibro-cartilaginous tissue. This condition may be disrupted by minor injury and result in an excruciatingly painful condition (Capasso & al., 1999), in which the excision of a bone fragment may be the most favourable option. The development of this situation before puberty is undoubtedly influ- enced by the tensile forces applied by the quadriceps femoris during the development of the individual (Ogata, 1994). Further, abnormal muscular traction by the vastus lateralis associated with possible vascular insufficiency is thought to play a role (Scapinelli & Capasso, 2000). In some case the abnormal patella can be the source of persistent pain and the cause of complete disability in the knee Conclusion. This case report describes a rare case of bipartite patella in an archae- ological contest. The specimen is from an adult male characterised by an intense right asymmetry in the upper right limb, who presumably used his right hand for work or related activities (possibly because his left arm was occupied by the use of a walking stick). The impossibility of using the other patella for comparative purposes limits our analysis. As noted in the medical literature, this condition is more common in males. The typology of the longitudinal bipartition of the bone of the knee identifies this example as ‘type II” that, according to the literature, represents a moderate expression of the defect in Saupe’s (1921) disease typology. References. Adams J D & Leonard R D 1925 A developmental anomaly of the patella fiequently diagnosed as facture Surgical Gynaecological Obstetrics 41: 601-604. Anderson T 2002 A Bipartite Patella in a Juvenile from a Medieval Context international Journal of Osteoarchaeology 12: 297-302 Baker B J Dupras T L & Tocheri M W 2005 Osteology of Infanis And Children Texas A&M University Press. Blumeensaat C 1932 Patella partita Traumatische Spaitpatella Patellarfrakur Arch Ortop 72: 117-122. Bruzek J 2002. A method for visual determination of sex using the human hip bone American Journal of Physical Anthropology 117: 157-168. Capasso L Kennedy KAR & Wilezak CA 1999 Atlas of occupational markers on human remains Edigrafital Spa Teramo — Italy D’Alo R Pozzi L & Salvi V 1962 Rotula Partita Considerazioni _istopatologiche © —_clinico- radiografiche su 61 casi Arch Ortop 72: 268-282. Duthic RB & Bentley G 1996 Mercer's Orthopaedic Surgery (Sth edition) Amold London Finnegan M 1978 Non metric variation of the infra cranial skeleton Journal of Anatomy 125: 23-37. George R_ 1935 Bilateral bipartite patellae British Journal of Surgery 22: 555-560. Green W Y 1975 Painful bipartite Patella of three eases Clin Orthop 10: 197-200. A report 60 Journal of Paleopathology 19 (1-3)Gruber W 1883. In Bildungsanomalic mit Bildungshemmung begriindete Bipartition beider Patellac cines jungen Subjektes Virchows Archive 94: 358-361 Mann R W & Murphy S P 1990 Regional Atlas of Bone Disease CC Thomas Springfield Marella G L. 2003 Elementi di antropologia forense Cedam. Meindl RS E & Lovejoy C O 1985 Ectocranial Suture Closure A Revised Method — for Determination of Age and Death Based on the Lateral Anterior Sutures American Journal of Physical Anthropology 68: 57-66. Messeri P 1958 Note di Paleopatologia sui neolitici della Liguria. Archivio per I'Antropologia ¢ V’Etmologia 88: 101-119. Messeri P 1961 Morfologia della rotula nei neolitici della Liguria, PAntropologia PEtnologia. 91: 1-11 Miles A E W 1963 The dentition in assessment of individual age in skeletal material Denial Anthropology Symposia of the Society of Human Biology 5: 191-209. Murail P Bruzek J Houet F & Cunha E 2005 DSP A tool for probabilistic sex diagnosis using worldwide variability in hip bone measurements Bulletins et Mémoires de la Société d’Anthropologie de Paris 17: 167-176. Ogata K 1994 Painful bipartite patella A new approach to operative treatment Journal Bone Joint Surgery 76-A: 573-578. Pass H_ 1931 Beitrige zur_nichttraumatischen Teilung der Kniescheibe (Patella partita) Deut Zeit Chir 230: 261-277. Resnick D & Niwayama G 1981 Diagnosis of Bone and Joint Disorders WB Saunders Philadelphia Saupe H 1921 Beitrag zur Patella partita Forschr Geb Roentg 28: 37-41. Scapinelli R_& Capasso L 2000 Partite and Emarginate Patella in victims of the 79 AD. vesuvian eruption Journal of Paleopathology 12 (2): 27-35. Scheuer L & Black $ 2000 Developmental Juvenile Osteology Academic Press London. Shulman $ 1955 Unilateral congenital duplication of the patella British Journal of Radiology 28: 164- 165. Silverman F N & Kuhn J P 1993 Caffey’s Pediatric X-Ray Diagnosis An Integrated Imaging Approach (9th edition) Mosby St Louis. Soren A & Waugh TR 1994 Patella Partita Archives of Orthopaedic and Trauma Surgery 4: 196-198. Stuke K 1950 Die Patella partita in ihren Beziehungen zum —-Unfall,=—und_— zur Wehrdienstbeschaidigung Monatsschr unfall 53: 238-244. Tachdjian M © 1990 Pediatric Orthopedics (2nd edition) WB Saunders Philadelphia Wright W 1904 A case of accessory patellae in the human subject with remarks on emargination of the patellae Journal of Anatomy 38: 65-67. Journal of Paleopathology 19 (\-3) 61JoP. 19 (1-3) 2007: 63-71 OS ODONTOIDEUM AND NEUROPATHIC ARTHROPATHY (CHARCOT’S JOINT) OF THE ELBOW IN A MALE FROM NINETEENTH CENTURY, U.S.A. M. S. Phillips* Lv Abstract. Os odontoideum, Type I fracture and detachment of the dens, is rarely recovered from archaeological contexts since it represents the survival of upper cervical vertebrae fracture in past populations. This study documents such an example and links the cervical trauma to the observation of a neuropathic arthropathy (Charcot’s Joini) of the elbow, a condition commonly associated with disruption to normal nerve functioning due to trauma or interruption of the spinal cord. As with os odontoideum, few cases of neuropathic arthropathy have been reported from archaeological contexts. This analysis discusses the differential diagnosis of both lesions and suggests that the trauma that caused in os odontoideum also resulted in trauma to the spinal cord that, over time, led to the Charcot's Joint of the elbow. Introduction. Os odontoideum is a Type II fracture of the dens that remains rarer are examples of individuals from past populations that survive traumatic fracture to the cervical spine (Capasso detached once (or if) the individual survives the trauma (Pathria, 1995; Scheuer & Black, 2000). Examples of trauma to the cervical vertebrae report- ed from archaeological contexts are rare with the exception of cases of execution by hanging (Merbs, 1989; Roberts & Manchester, 1995). Even & al., 1999; Hill & al., 1995; Phillips, 2001 & 2005). This study presents an analysis. and description of an individual recovered from the cemet- ery of a nineteenth century asylum for the mentally ill, in upstate New York, US, who exhibits evidence of an os odontoideum, In addition to the trauma “Department of Geography, Geology, and Anthropology, Indiana State University. Terre Haute, IN 47809,to the cervical spine, the individual also exhibits evidence of a neuropathic arthropathy (Charcot’s Joint) of the elbow. This condition is rarely report- ed in archaeological contexts and, even more rarely, is there skeletal evidence to indicate the precipitous cause of the lesion. In conjunction with the skeletal observations, this study considers the asylum context and historical and modern medical diagnostic and pro- gnostic methods to interpret the suite of lesions present in this individual. Fractures of the odontoid process make up 55% of all axis fractures and are the most common fracture of the second cervical vertebra (Pathria, 1995; Rockwood & el. 2005; Schuller & al., 1991). Such trauma is not well understood, but is observed to be “the result of a combination of flexion, extension, or rotation with a shearing force” (Pathria, 1995). In modern populations these fractures are asso- ciated with the major force that accompanies motor vehicle accidents. and falls (Pathria, 1995; Schuller, 1991). As stated above, few studies report on fracture to the upper cervical spine from archaeological contexts, and even fewer cases document survival from such injuries. For modern populations, in contrast, the clinical literature is rich with radio- graphic diagnostic techniques, surgical, and stabilization implements (such as the “halo ring”) to treat contemporary cases of such trauma (Pathria, 1995; Rockwood & al. 2005). In an example from an archaeological context, Phillips (2001, 2005) describes an individual with healed fractures of the first and second cervical vertebrae and diagnoses the fractures as Porter’s Neck of Levy. In the same individual, Phillips describes a possible pseudo- arthrosis of the neural arch of the axis. Also, Hill & al. (1995) report on individuals from an archaeological setting with healed Jefferson’s frac- tures of the atlas. The current study adds another example to the very few cases that identify healed fractures of the cervical spine from archaeological contexts. Charcot’s Joint is typified by excessive osteoarthritic destruction and remodeling that culminates in a locked immobile joint. The condition is believed to result from nerve damage and a subsequent loss of sensation in the region of the joint. The loss of sensation leads to repeated non-sensed injuries to the affected joint. The traumatic damage to the joint can be quite notable in just a few months (Aufderheide & Rodriguez-Martin, 1998). Ortner outlines the four most common causes of Charcot’s Joint as 1) tabes dorsalis, a late manifestation of neurosyphilis, 2) syringomyelia, a cyst impinging on the spinal cord, 3) diabetic neuropathy, and 4) traumatic nerve damage (Ortner, 2003). Al- though the etiology of Charcot’s Joint is known, a clear diagnosis can be uncertain even in clinical cases (Resnick, 1995). The current study 64 Journal of Paleopathology 19 (1-3)suggests that the Charcot’s Joint in this individual was the result of traumatic nerve damage, specifically associated with os odontoideum. A thorough literature search by the author has not identified any published descriptions of Charcot’s Joint of the elbow from archaeological contexts to compare with the current analysis. Ortner (2003) and Auderheide and Rodriguez- Martin (1998) discuss cases of the condition from skeletal materials from museum research collections, which serve and the primary comparative examples. Historical Context. The individual under investigation in this study is from the cemetery associated with the Oneida County Asylum (OCA). The OCA was a custodial institution for the mentally ill that was in operation from 1860 to 1895 in central New York State, U.S.A. Dr. Michael West, the asylum’s attending physician, made detailed records of a variety of falls (from windows, wagons, and simply from a standing position) with injurious con- sequences, the most serious of which was death. The physician made no mention, however, of trauma to the cervical spine or of lingering physical consequences related to falls (Phillips, 2001). Phillips (2003) compared the extra-spinal fracture patterns of the asylum sample with that of skeletal collections that represent the general population from that temporal context. That study reported higher frequencies of trauma to the hands and feet in the individuals in the asylum sample. The increased frequency of trauma to the extremities was interpreted as exposure to differential risks of trauma in the asylum context in comparison to the general population. Furthermore, Phillips (2001; 2005) reported a possible pseudoarthrosis of the axis on another individual from this collection that suffered and survived fracture to the axis and atlas. Given the absence of discussions of individuals with cervical fractures in the Oneida Asylum medical records or in the inmate case files, it is possible that the individuals suffered and survived cervical frac- tures without anyone realizing they had suffered such trauma. It is likely that many inmates in the OCA may have suffered from conditions that went unnoticed and untreated simply because the individuals were not capable of reporting their symptoms. Materials and methods. This study presents a detailed skeletal analysis of an individual with two unique, and possibly associated, skeletal lesions. The most salient of the two lesions was observed on the left elbow joint, which exhibits dramatic osteoarthritic remodeling and ankyl- osis. The other lesion was observed on the axis, where the dens was fractured and detached. Differential diagnosis protocols were followed to suggest a possible interpretation of each lesion Journal of Paleopathology 19 (1-3) 65(Aufderheide & Rodriguez-Martin, 1998; Lovell, 1997; Merbs, 1989; Ortner, 2003) for discussions of skeletal fractures from archaeological contexts. The analysis also investigates clinical manifestations of Charcot’s Joint and fracture of the dens (Pathria, 1995; Resnick, 1995; Rockwood & al., 2005; Scheuer & Black, 2000; Schuller, 1991). The current analysis was derived from a larger study (Phillips, 2001) of the overall trauma patterns in this skeletal sample, which provides details on the range and pattern of skeletal trauma in the OCA sample. Standard skeletal sexing and aging methods (relying on cranial and pelvic observations) were followed in this study (Buikstra & Ubelaker, 1994). These data were considered with the bone fractures in order to develop a biocultural interpretation. Results. The skeletal inventory revealed a well-preserved skeleton that was complete with the exception of the feet and the distal quarter of the right and left tibiae and fibulae. The skeletal elements were lost due to sub-surface disturbances from prior construction activities. The individual is an adult male approximately 40 (+/- 5) years old. Age estimation was based on analysis of the pubic symphyses, auricular surfaces of the os coxa, and sternal rib morphology. All age indicators were in concurrence with the above stated age estimation. Sex was Figure 1. Images A. (dens) and B. (Anterior aspect xis with dens fracture), demonstrate the idence that this individual suffered and survived fracture of the dens of the axis. Photograph taken by author, courtesy of the New York State Museum, Albany, NY. U.S.A. determined through pelvic and cranial observations. The sciatic notch was deep and narrow, the medial aspect of the ischio-pubic ramus was broad, and the sub-pubic concavity was absent. In addition, all cranial observations were robust and supported the sex deter- mination as male. The most salient aspect of the analysis was the observation of two discrete skeletal lesions. The first lesion involved the axis (Figs. 1 and 2). The dens is fractured and detached at the 66 Journal of Paleopathology 19 (1-3)Figure 2. This image exhibits the axis (above) and atlas (below). The axis shows extensive remodeling at the dens attachment site and the atlas shows remodeling on the dens articulation facet Photograph taken by author, courtesy of the New York State Museum, Albany, NY. U.S.A. odontoid isthmus. In Figure 1B, the anterior margin of the dentrocentral junction bears a transverse ridge of remodeled bone. Note, in Fig. 2, that the dens attachment site on the superior aspect of the axis is irregularly rugose and exhibits remodeling. In Fig. 2, the dens articular facet on the atlas exhibits ostcoarthritic remodeling. The second lesion involves ankylosis of the left elbow joint (Figs. 3, 4 and 5), which had remained in the locked position even after interment (Fig. 6). The articular surfaces of the left distal humerus and proximal ulna dem- onstrate excessive — osteoarthrite remodeling and destruction. Within the fused joint, it appears that all cartilaginous tissues and subchondral bone were obliterated, as there are complimentary deep groove lines along the ulnar olecranon process and former site of the humeral trochlea. Discussion. There is skeletal evidence of traumatic injury to the axis that is likely to have intruded upon the spinal cord. The dens of the second cervical vertebrae is fractured and detached at the odontoid isthmus, such detachment is clinically defined as an os odontoideum (Scheuer & Black, 2000; Schuller & al., 1991) and classed as a Type Il dens fracture (Pathria, 1995; Rockwood & al., 2005). Os odontoideum can result from either congenital or traumatic causes. Fusion of the dentrocentral junction normally occurs between four and six years of age (Scheuer & Black, 2000). It is possible, within human variation, for the dens to not fuse to the axis and simply remain attached via cartilage However, when the dens fails to fuse, the area where the dens should attach is very smooth and a dens facet on the atlas is absent (Barnes, 1994; Schuller & al., 1991). Since the dens is detached and the dens attachment site in this individual exhibits excessive Journal of Pateopathology 19 (1-3) 7Figure 3. This image demonstrates the Charcot’s Joint of the elbow (proximal ulna and distal humerus) and the position in which the joint was locked, Photograph taken by author, courtesy of the New York Siate Museum, Albany, NY. U.S.A. igure 4. This image demonstrates the degree of Figure 5. This image compares the right and left remodeling of the left proximal ulna (the one distal humeri. The left, involved in the Charot’s involved in the Charcot’s Joint in comparison the Joint, exhibits extreme damage and remodeling. The it proximal ulna). Photograph taken by author, right appears relatively normal. Photograph taken by courtesy of the New York State Museum, Albany, author, courtesy of the New York State Muscum, NY. US.A. Albany, NY. U.S.A, 68 Journal of Paleopathology 19 (1-3)Figure 6. This image demonstrates the mortuary position of this individual and that the locked Charcot’s Joint remained immobile even after interment. Photograph taken by author, courtesy of the New York State Museum, Albany, NY. U.S.A. remodeling, it is likely that these observations are the result of fracture from traumatic injury. Also, the dens facet on the atlas is remodeled, indicating normal articulation before the suggested trauma. The ankylosis and excessive osteo- arthri destruction of the left elbow joint is characteristic of Charcot’s Joint, a neuropathic arthro- pathy. The degree of bony destruction and remodeling at the left elbow joint of this individual is clearly out of proportion with the rest of the body. Neuropathic arthropathy is a condition that results from a loss of sensation in the limbs due to spinal nerve damage (Auferderheide & Rodriguez-Martin, 1998; Ortner, 2003; Resnick, 1995), Due to the loss of sensation, the affected joint of a limb can be repeatedly and painlessly injured. Within only a few months the repetitive trauma can lead to dramatic joint remodeling (Aufderheide & Rodriguez-Martin, 1998). Of the four common causes of Charcot’s Joint, only two are testable from skeletal remains. Neuropathy arthropathy res- ulting from complications associated with diabetes and syringomyelia, a cyst impinging on the spinal cord, are not likely to leave diagnostic skeletal manifestations. The other two causes of Charcot’s Joint, syphilis and trauma, however, often leave a diagnostic skeletal record. Since there was no evidence of treponemal infection in this individual, this cause can be Journal of Paleopathology 19 (1-3) 9eliminated as a possible cause of the joint trauma. In order to determine the cause of the trauma in this temporal and cultural context, medical texts from the period were consulted. Among the rare cases of dens fractures reported from the late nineteenth/carly twentieth century in which the individuals survived, Stimson (1912) discusses loss of sensation to the left arm as a consequence. Likewise, Scheuer and Black (2000) explain that os odontoideum can have _ lingering consequences affecting the region of the neck and upper limbs. Although it may not always be possible to diagnose the etiology of neuropathic arthropathy in contemporary clinical cases (Pathria, 1995), it seems parsimonious to suggest that the fracture to the dens damaged the spinal cord in this individual and resulted in the Charcot’s Joint. This assertion must remain tenuous, however, since it is not possible to eliminate the two remaining common causes of neuro- pathic arthropathy. It is not possible to test for diabetes or most soft tissue pathologies, such as syringomyelia, in skeletal remains. Still, given the presence of the trauma to the second cervical vertebra, it seems that etiology of the Charcot’s Joint in this individual is likely the result of that trauma. Acknowledgments. I wish to thank Lisa Anderson (New York State Museum) and Brenda Baker (Arizona State University) for access to the OCA collection and for providing lab space during my Research Residency at the New York State Museum, NY, USA. I also thank Susan Berta (Indiana State University) for providing the research support needed to complete this project. References. ‘Aufderheide A & Rodriguez-Martin C 1998 The Cambridge Encyclopedia of Human Paleopathology Cambridge University Press Cambridge. Bares E 1994 Developmental Defects of the Axial Skeleton in Paleopathology Niwot CO University Press of Colorado. Buikstra J & Ubelaker D 1994 Standards for Data Collection from Human Skeletal Remains Atkansas Archeological Survey Research Series n 44 Fayetteville AS Arkansas Archeological Survey. Capasso L Kennedy K. & Wilezak C 1999 Atlas of Occupational Markers on Human Remains. Journal of Paleontology — Monographic Publication 3 Edigrafital SpA Teramo. Hill M Blakey M & Mack M 1995 Women, Endurance, Enslavement: Exceeding the Physio- logical Limits. Paper presented at the 94" Annual meeting of the American Association of Physical Anthropologists Oakland CA. Lovell N 1997 Trauma Analysis in Paleopathology Yearbook of Physical Anthropology 40:139-170. Merbs C 1989 Trauma, In Isean M & Kennedy K (eds) Reconstruction of Life From the Skeleton Liss New York, pp. 161-189. Ortner D 2003 Identification of Pathological Conditions in Human Skeletal Remains Second Edition Academic Press New York. Pathria M 1995 Physical Injury Spine In D Resnick (ed.) Diagnosis of Bone and Joint Disorders, 3”. Philadelphia Saunders pp. 2825-2898, Phillips S 2005 Axis and Atlas Fracture with Healing and Non-Union in an Inmate from a Nineteenth Nentury Asylum for the Mentally IL 70 Journal of Paleopathology 19 (1-3)New York USA Journal of Paleopathology 17Q).65-70. Worked 10 the Bone 2003: The Biomechanical Consequences of ‘Labor Therapy’ at a Nineteenth Century Asylum In Swedlund A & Herring A (eds) Human Biologists in the Archives: Demography, Health, Nutrition, and Genetics in Historical Populations. Cambridge University Press Cambridge 96-129. Inmate Life in the Oneida County Asylum 1865- 1890 A Biocultural Analysis of the Skeletal and Documeniary Records 2001 Doctoral dissertation Department of Anthropology SUNY Albany NY USA. Resnick D 1995 Neuropathic Osteoarthropathy In Resnick D (ed.) Diagnosis of Bone and Joint Disorders 3° Philadelphia Saunders 3413-3442. Roberts C & Manchester K 1995 The Archeology of Disease Second Edition Whaca NY Comell University Press. Rockwood C Green D & Bucholz R 2005 Rockwood and Green's Fractures in Adulis Volume 2.6" ed Lippincott 1B Co New York. Scheuer L & Black $ 2000 Developmental Juvenile Osteology New York Academie Press. Schuller T Kurz L Thompson E Zemenick G Hensinger R & Herkowitz H 1991 Natural History of Os Odontoideum Journal of Pediatrie Orthopaedics \1:222-225 Stimson L 1912 4 Practical Treatise on Fractures and Dislocations Seventh Edition Lea & Febiger New York Journal of Paleopathology 19 (1-3) nJ.0.P, 19 (1-3) 2007; 73-80 HARRIS LINES IN THE LONG BONES OF THE LIMBS R. Scapinelli* R. D’Anastasio** L. Capasso** Abstract. The authors review basic information on transverse lines of increased density, also called Harris lines, visible radiographically in the-bones of some subjects as a consequence of generalized illnesses or stresses suffered during childhood. They reflect episodes of delayed or arrested development of the longitudinal growth of the bone. These lines are often an occasional finding in living people, and may offer useful information in both paleopathology and the medico-legal fields. Introduction. Harris lines are transverse lines of increased density occasionally found in the roentgenograms of the long bones of the extremities. They vary in number and are usually bilateral. They form near the epiphyseal plates during childhood and are thought to indicate temporary arrests of longitudinal growth as a result of various diseases, metabolic disorders, stress, or trauma. The mechanism of their formation has been elucidated in meticulous studies by a number of authors, who have demonstrated a dissociation between the activity of the cartilage cells and the osteoblasts. The interpretation of these radiologic images is important both in the anthropological and medico-legal fields, which justifies a review of the pertinent literature and the report of our own personal radiological docu- mentation of a very interesting case. History. In the pre-radiologic era, transverse lines of increased density in the meta- physes were first observed by Wegner (1872, 1874) in young experimental *Siate Unive **State University “G. d’Annuncio”, Trento e Trieste 1, 66100 Chieti (Italy). ty of Padova, Orthopaedic Clinic, Via Giustiniani 3, 35122 Padova (Italy) Faculty of Medicine and Surgery, Section of Anthropology, Piazzaanimals following the administration of elementary phosphorus. Analogous effects were produced experimentally using arsenicus. Transverse bands were described in children affected by scurvy (Lehndorff, 1904), rickets (Phemister, 1918), and lead and bismuth intox- ication (Park et al., 1931). Harris lines were first described in the earky years of the 20" century when Ludlof (1903) recognized themin radiographs of the leg bones of normal individual. In a series of fundamental articles, H. A. Harris (1926, 1931, 1933), professor of Anatomy at University College of London, reviewed the history of the condition and studied the clinical and exper- imental causes able to produce transverse lines near the epiphyseal plate of the long bones. On the basis of his studies Harris expressed the opinion that these lines of growth arrest should be regarded as a marker of a past episode of disease. The opinions of Stettner and Harris on the formation of these lines were embraced also by Park and Richter (1953) and Dreizen ct al (1964) who underlined the importance of the restarting of osteoblastic activity after a phase of arrest or slowing of the epiphyseal cartilage growth. Aetiology. ‘A number of pathologic conditions were considered potential causes of epiphyseal growth arrest and the formation of transverse lines. These causative conditions may be specific or non-specific. Apart from heavy metals poisoning (lead, arsenicus, phosphorus, bismuth), specific disorders that may produce zones of increased density in the growing bones are scurvy, rickets, and congenital syphilis, in which radiopaque transverse zones are produced by accumulation of calcified cartilage matrix material (lattice), which cannot converted into bone due to a deficit of osteoblasts and cap- illaries. Other specific causes are those of hormonal nature, ie. from estrogens, parathormon, or HGH ad- ministration. The non-specific causes of bone growth arrest include temporary conditions both of short or longer duration, such as acute febrile illnesses (pneumonia, tonsillitis, dysentery, etc) dietary restrictions or malnutrition (especially protein de- privation, Platt & Steward, 1963), metabolic disturbances, acute or chronic anemia, metabolic disturb- ances (mainly diabetes mellitus), antiblastic therapies, and stresses of various nature (fractures, etc). An individual response to various causes has been advocated (Dreizen et al, 1966) and this explains why only in 25 per cent of cases an episode of illness is followed by formation of a transverse line (Gindhart, 1968). Location and radiographic appear- ance: Harris lines may be observed in many bones, including the pelvis, scapula, and calcaneus, but they are 74 Journal of Paleopathology 19 (1-3)more frequently and more easily seen in the epiphyseal-shaft junction of the distal end of the radius and femur and the proximal and distal tibia, due to the fact that those are the fastest growing long bone regions of the skeleton. On the x-rays they appear as transverse lines of increased density, usually symmetrically located at the same level in both sides, parallel to the epiphyseal plates (Fig. 1). Depending on their size, they may extend completely across the medullary canal, or may be only partially developed within the canal. The thickness of the lines rarely exceeds one-half millimeter. The transverse lines may be single but more frequently multiple and in this case they lay parallel to one another at a variable distance. There is no correlation between the number of Harris lines and number of pathologies or stresses suffered (Marshall, 1968). Mechanism of formation and destiny: The most important contribution to the understanding of the pathogenesis of the Harris lines came from Park et al (1953), Follis and Park (1952) and Garn et al. (1968; Garn, 1981). The histological studies of these authors stated that Harris lines originate from a temporary cessation or interruption of endochondral bone growth in the metaphysis of the long bones of growing subjects, following a period of disturbed bone metabolism. Non- specific stresses or diseases of various types, lasting a number of days or Fig. 1. Radiograph of both tibias and fibulas of St. Luke the Evangelist I" Century AD): anterior view. The distal epiphyses of both tibias display transverse lines in increased density (white arrows): Harris lines. weeks, cause interruption or slowing of the proliferative activity of the carti- lage cells of the growth plate, with parallel reduction of the osteoblastic activity and vascular penetration. Through an unknown mechanism, the osteoblasts and the accompanying vessels become unable to invade and convert into bone the vertical septa formed by the calcified matrix framework between the cartilage Journal of Paleopathology 19 (1-3) 15columns and the lacunae left from degeneration and dissolution of the hypertrophic cartilage cells. Neverthe- less, while the osteoblasts maintain a reduced vital energy in the vertical direction, they are forced to address their major activity in the horizontal plane, parallel to the epiphyseal plate (Park et al., 1953). In other words the horizontal plane is the only possible space for growth expansion (Follis & Park, 1952). Only sporadically do the osteoblasts and accompanying vessels penetrate the empty lacunae of the cartilage cells of the lower part of the lattice. Also, osteoclastic activity in the oldest part of the lattice (i.e., on the shaft side) is not completely suppressed. Osteoblastic activity takes place laterally in all directions (Follis & Park, 1952). As a result of osteoid deposition on the matrix framework located at the undersurface of the cartilaginous plate, the osteoblasts become osteocytes and there is formation of transverse trabecula in the horizontal plane which forms an interlacing tridimensional network, where horizontally directed trabeculae are joined each other to form a stratified structure of various width, the Harris line (Follis & Park, 1952). The thickness of the line depends on the duration of arrested growth and the thickness of the cartilaginous block (Lewis, 2000). Once the temporary causative condi- tions are resolved, the normal process of proliferation and maturation of the cartilaginous cells begins again and longitudinal bone growth is resumed (Follis & Park, 1952; Dreizen et al., 1956). But proliferation and sense- cence of the cartilaginous cells and convergence of the capillaries requires time and during this time the Harris line continues to increase its thickness (Follis & Park, 1952). Histologically, the Harris line mainly consists of bone tissue but it also includes remnants of the original calcified cartilaginous matrix, in which there are intact cartilage cells. A slight degree of growth continues to occur, furnishing an increased amount of horizontally disposed matrix frame- work for the osteoblasts to settle upon. The Harris line originates in the metaphysis of a rapidly growing bone, but subsequently becomes widely separated from the metaphysis as a consequence of the resumption of normal longitudinal bone growth; consequently, it appears to be pushed toward the center of the diaphysis, but this is an illusion, as it does not actually ‘drift’ after formation. A Harris line is radiographically invisible at the beginning, because it initially forms very close to the cartilage of the epiphyseal plate. Later on, the multiple strata of horizontally directed trabeculae composing the Harris line appear on the roentgen- ogram as transverse lines of increased density, which become more or less largely separated from the plate as a consequence of growth. They may be 16 Journal of Paleopathology 19 (1-3)only partially developed and in this case they form a discontinuous line, formed by small groups of bony trabeculae here and there (Follis & Park, 1952). When multiple lines are present, they lare laid down one above the other at a variable interval, as a consequence of bone lengthening. The oldest Harris line that formed in early years of life is the one most widely separated from the epiphyseal line. The physiological process of bone remodelling may cause complete or partial resorption of Harris lines with time (Marshall, 1968). But in most cases these “bone scars” remain visible on roentgenograms during life, in some cases until 90 years of age (Garn et al., 1968; Dreizen et al., 1956; Garn & Schwagger, 1967). Practical importance of the Harris line: Because Harris lines remain in the original position in which they have formed within a given bone, they should be considered as natural bone markers, which testify to one or more periods of delayed or arrested longitudinal bone growth suffered during childhood, due to disturbances of chondroblastic, osteoblastic and activities. The cause of their formation can be only hypothesized in ancient skeletons (diseases of various sorts, nutritional stresses, malnutrition, dietary imbalance, poisoning, etc.). The thickness of the Harris line can reflect the length of the period of disease or stress (Lewis, 2000). In living persons, the transverse lines have been used also to measure the amount and rates of growth and remodelling of the various bones through the use of seriated radio- graphic controls at 1, 2 and 5 years (Follis & Park, 1952; Garn et al., 1968; Garn, 1981). Anamnesis usually allows individuation of the possible causative diseases or stresses suffered in child- hood. In the paleopathologic field (Wells, 1967; Drusini et al. 2001; Piontek et al., 2001) the presence and number of Harris lines can be used to evaluate the health status (index of morbidity) of different ancient populations. Furthermore, through specific calcula- tions it is possible to judge the age of a child at the time of formation of a particular line, especially in the tibia. In other words, the timing of an acute childhood illness or stresses of various sorts can be dated by the specific location of a Harris line within the bone. The methods which can be used for this purpose are many (Ubelaker, 1989: Sanchez Sanchez et al., 1992; Byers, 1991). With Ubelaker’s method, the age of formation of the lines is obtained on the basis of the maximum length of the entire bone (tibia) and the distance which separates the lines from the cartilage-shaft junction, where the lines were formed. With the method of Sanchez et al., one calculates the percentage of growth of the tibia at the moment of formation of the Harris line. This can be obtained by the use of Journal of Paleopathology 19 (1-3) 7(years) 7,5-8,5 8,5-9,5 12,5-13,5 Fig. 2. Radiograph of the distal epiphysis of left tibia of St. Luca the Evangelist (I Century AD) showing Harris lines (A) and its schematic drawing displaying the age of their formation (B). the table of Hummert and Van Gerven (1985). In adults, the Byers’ method has the advantage of being easy to use and it requires taking only two measurements of the long bone under study (Piontek & al., 2001). In our earlier study of St. Luke the Evangelist (Scapinelli & Capasso, 2003, illustrated here in Fig. 2), Ubelaker’s method allowed us to estimate that the Harris lines present in both tibiae were formed between the ages of 7,5-8,5, 8,5-9,5 and 12,5-15,5 years. In the Piontek et al. series (2001) the highest frequency of Harris lines occurred in children of 9 to 11 years of age. This agrees with the results reported by many other authors and in particular by Hughes ct al (1996) who noticed that the highest number of arrested growth lines were formed at the age of 10-11 years. 8 Journal of Paleopathology 19 (1-3)Formation of lines at earlier ages were observed by other authors in skeletal material collected in different places (Wells, 1961; Goodman & Clark, 1981), and these data were confirmed in contemporary populations (Gindhart, 1969). References. Byers S 1991 Technical note: calculation of age at formation of radiopaque transverse lines Am J Physical Anthropology 9: 433-470. Dreizen $ Currie C Gilley E J & Spies T D 19: Observations on the association between nutri failure skeletal maturation in rate and radiopaque transverse lines in the distal end of the radius in children Am.J Roentgenology 76: 482-487. Dreizen S Spirakis C N & Stone R E 1964 The influence of and nutritional status on “bone scars” form in the distal end of the growing radius Am J Phys Anthrop 22: 295-306. Drusini A G Carrara N Orefici G & Rippa Bonati M 2001 Paleodemography of the Nasca Valley: reconstruction of the human ecology in the southern Peruvian coast Homo 52 2: 157-172. Follis R H & Park E A 1952 Some obsertations on bone growth with particular respect to zones and transverse lines of increased density in the metaphysie Am J Roentgenology 68: 709-724. Gam S M 1981 Contributions of the radiographic image to our knowledge of human growth AJR 137: 231-239, Gam S & Schwagger P 1967 Age dynamics of persistent transverse lines in the tibia Am J Physical Anthropology 27: 375-377. Gam S M Silverman N Hertzog P & Rohmann G 1968 Lines and bands of increased density Med Radiogr Photogr 44: 58-89. Gindhart PS 1968 The frequency of appearance of transverse lines in the tibia in relation to childhood, illnesses Am J Phys Anthrop 31: 17-22. Goodman A & Clark, G 1981 Harris lines as indicators of stress in prehistoric Illinois population In Martin D & Blumbest M (eds.) Biocultural adapiation: comprehensive approaches to skeletal analyses Research report pp 35-47, Harris H A 1933 Bone growth in heaith and disease ‘Oxford University Pres p 87. Harris HA 1931 Lines of arrested growth in the Jong bones in childhood, Correlation of histological and’ radiographic appearances in clinical and experimental conditions Brit J Radio! 4: S61-588 4:622-640. Harris H_A 1926 The growth of the long bones in childhood with special reference to certain bony striations of the metaphysic and to the role of vitamins Arch Intern Med 38: 785-806. Hughes C Heylings D & Powers D 1996 Transverse (Harris) lines archaeological remains Am J Physical Anthropology 101: 115-131. Hummert J & Van Gerven D 1985 Observations on the formation and persistence of radiopaque transverse line Am J Physical Anthropology 66: 297-3006. Lehndorff, 1904 Zur Kenntniss der Morbus Balow Rontgenbefund Arch (Kinderh 38: 161 Lewis M 2000 Non-adult palcopathology: current status and future potential In Human osteology in archaeology and forensic science Cox M & Mays S pp 39-57. Ludlof K 1903 Uber Wachstum un Architektur der unteren Femurepiphyse un oberen_tibiaepiphyse. Ein Beitrag zur Rontgendiagnostik Bruns Beitrag zur Klinische Chirurgie 38: 64-75. Marshall W 1968 Problems in relating the presence of transverse lines in the radius to the oceurrence of disease In Brothwell D (ed.) The skeletal biology of earlier human populations Research reports Pergamon Press pp 241-261. Journal of Paleopathology 19 (1-3) 19Park EA & Richter C P 1953 Transverse lines in, the bone: mechanism of their development Bull John Hopkins Hospital 13: 234-248, Park E A Jackson D & Kajdi L 1931 Shadows produced by lead in the x-ray pictures of the ‘growing skeleton Am J Dis Child 41: 485-499. Park E & Richter C P1953 Transverse lines in bone: the mechanism of their development Bull Hopkins Hospital 13: 234-248. Phomister D B 1918 The effect of phosphorus on growing normal and diseased bones Jama 70: 1737- 1743 Piontek J Jerszynska & B Nowak © 2001 Harris Line in subadult and adult skeletons from the mediaeval cemetery in Cedynia Poland Variability and Evolution 9: 33-43 Platt B & Steward R_ 1962 Transverse trabecul and osteoporosis in bones in experimental prot calorie deficiency British Journal Nutrition 16: 483- 495. Sanchez Sanchez J A, Gomez Bellard F, & Arroyo Pardo E 1992 Estudio de las lineas de Harris en los restos 6seos medievales de la iglesia de San Francisco Medina de Rio Seco (Valladolid) Munibe Antropologia-Arkeologia 8: 213-216. Scapinelli R & Capasso L 2003 Studio radiologico delle ossa aitribuite a San Luca Evangelista Atti del Congreso. Internazionale Padova 16-21 ottobre 2000. von Wegner G 1872 Der Einfluss des Phosphors auf den Organismus Virchows Arch f Path Anat 55: 11-45. von Wegner G 1874 Ueber das normale und pathologische Wachstum der _Roehrenknochen Virchows Arch f Path Anat 61: 44-76. Wells C 1967 A new approach to paleopathology: Harris’s Lines In Brothwell DR & Sandison AT (eds) Diseases in Antiquity Springfield Thomas pp 390-404. Ubelaker DH 1989 fluman skeletal remains. excavation, analysis, interpretation Washington Taraxacum. 80 Journal of Paleopathology 19 (1-3)INSTRUCTION FOR AUTHORS. SUBMISSION Manupscripts should be addressed to. 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