Resurrecting Pompeii (34 page)

While signs of skeletal change that were consistent with infective lesions were observed on some of the disarticulated skeletal elements of the Pompeians, they were nearly impossible to interpret, unless they were related to a specific cause, like a dental abscess or osteomyelitis resulting from a compound fracture.
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The Herculaneum material is much better suited to such studies as the entire skeleton is usually available and patterns of bony change across the body can be interpreted to establish a diagnosis.

Capasso and his colleagues documented a number of bone reactions in response to inflammation on the skeletons of the Herculaneum sample. Capasso and Di Tota noted a small flattened oval area on the outer table of the skull in 37.6 per cent of the adult sample, usually about 20 mm in diameter, with superficial bone remodelling. It was claimed that these reflected healing irritation to the periosteum as a result of scratching to relieve discomfort from infestations of head lice. This interpretation was based on the discovery of a single louse egg found preserved on a hair on the head of one of the individuals who presented with this pathology. This may well be stretching the evidence as it would take quite a bit of scalp scratching to involve the underlying bone. Capasso argued that inflammatory bone reaction observed on the dorsal surface of the first and fifth metatarsals and the superior surface of a tarsal on 25.8 per cent of the adults, was due to wearing Roman sandals and shoes. He also argued that local inflammatory reactions observed on the pleural surface of the ribs of 20.4 per cent of the adult sample were a reflection of lung infections from long-term exposure to particle pollution due to cooking and heating in poorly ventilated living areas. It should be noted that these conclusions are based on very limited evidence. Further, he observed local inflammatory reactions in the maxillary sinus as a result of the spread of dental infection.
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Pathological skeletal changes to the ribs and vertebrae that were indicative of tuberculosis were documented in two adults in the Herculaneum sample. Tuberculosis is caused by a bacterium that belongs to the genus
Mycobacterium
. Skeletal involvement generally only occurs after long-term illness, which means that most cases are not detected in the archaeological record. Capasso suggested that it was possible that the disease may have been contracted by the consumption of undercooked infected oxen viscera after ritual sacrifice, though there were probably other sources of infection.
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Capasso observed skeletal changes, which he considered to be a re flection of brucellosis, in the lumbar vertebrae in 16 adults of the 162 individuals he examined in the Herculaneum sample. While this disease can occur in juveniles, it does not tend to affect the vertebrae and is unlikely to be detected archaeologically. The human form of this infectious disease is chronic infection of the lungs or other organs, with recurrent episodes of fever. It only presents on bones in about 10 per cent of cases, which means that it is difficult to establish the incidence of the disorder solely from the skeletal record. The vertebrae, especially those from the lumbar region, are most commonly involved, followed by long bones. Infection usually occurs as a result of ingesting dairy products made from infected animals, though it can also be contracted from meat and cuts that have come into contact with diseased animals. It is not easily transmitted between humans. Capasso invoked the discovery of bacteria in the one portion of carbonized cheese that has been discovered in Herculaneum as supporting evidence for his diagnosis. He considered that one of the two types of bacteria that he observed was consistent in dimensions and morphology with
Brucella
. The heat of the eruption, coupled with the subsequent burial environment, made it impossible to use molecular techniques to confirm identification.
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Subsequent research into the presence of bacteria in other carbonized food remains from Herculaneum led Capasso to suggest that the comparatively low rate of non-specific bone infection that he observed in the skeletal sample he studied could be attributed to the consumption of
Streptomyces
,a bacterium that produces a natural tetracycline with antibiotic properties.
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Porotic hyperostosis refers to porosity of the cranial vault and/or orbits. It is usually related to the resorption of the underlying cortical bone. This results in thinning and can lead to the complete destruction of the outer table of the cranial vault. Though the exact cause for these bony changes has not been isolated, they have been associated with nutritional deficiencies. It is suspected that porotic hyperostosis is related to anaemia, possibly iron defi- ciency anaemia, though it has also been suggested that it may be associated with high parasite loads. Nutrient losses due to diseases that cause diarrhoea have also been cited as a possible cause. A direct relationship has been observed between infection and porotic hyperostosis, possibly because iron may be diverted to help fight infection. Scholars like Stuart Macadam consider that porotic hyperostosis is a reflection of the interaction between customs, diet, parasites and infectious diseases. Trace element and amino acid analyses have revealed lower iron levels in the bones of archaeological specimens diagnosed as having porotic hyperostosis. These changes, which are also described as cribra orbitalia when they present as a collection of small apertures or pitting on the orbital roof, are considered to be more likely to occur during childhood. It has been argued that active lesions are only found in individuals between the ages of six months and twelve years of age.
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It is possible to distinguish between active and healed lesions. Active lesions have been defined as those which exhibit a sieve-like appearance. They display porosity, which is interspersed with increasingly thin bridges of bone. Healing cribrotic lesions can be recognized by the smooth lamellar texture of the orbital plate with bone filling the peripheral pores. The usual locations of porotic hyperostosis are the orbital surface of the frontal bone or parietal bones. The lesions are usually bilaterally symmetrical. In extreme cases, all the bones of the cranial vault can be involved.
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One hundred and thirty adult and adolescent skulls that were complete enough for assessment were examined for evidence of porotic hyperostosis.
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No significant lesions were observed on the cranial vault. Some degree of pitting, or cribra orbitalia was observed on the orbital roofs of 90 per cent of the skulls. Most of the cases (about 59 per cent) displayed minimal but unequivocal porosity, which could be seen with the naked eye. A number of cases (about 28 per cent) were more equivocal with barely discernible pits, which could only really be seen with the aid of a hand lens. Only about 3 per cent of the sample exhibited a medium degree of expression with coalescing pores. There was no evidence at all of cribra orbitalia on about 7 per cent of the sample and approximately three per cent of the orbits in this sample were too incomplete to assess. All the cases exhibited lesions that could be described as ‘healing’, which is consistent with an interpretation of incomplete remodelling of the bone after an episode of anaemia a considerable time prior to death.
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It is dif ficult to assess the pathological importance of such slight bony changes, though it is notable that they occur with a high frequency. In the past, cribra orbitalia was considered to be a good stress marker. It was interpreted as indicative of poor adaptation by a community to its environment. There has been a shift in attitude in the last decades and the current wisdom is that it is an indicator of successful adaptation to an environment as the presence of lesions reflects the workings of a healthy immune system. Iron-deficiency anaemia has been reinterpreted as a result of an adaptive response by an individual to the total pathogen load of the environment.
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It should be noted that the relationship between porotic hyperostosis and cribra orbitalia has been questioned and it has been proposed that they may not just be different manifestations of the same process. Histological examination of bone structure in the orbital roofs of skeletons displaying cribra orbitalia does not always support a diagnosis of anaemia. Alternative diagnoses include inflammation and osteoporosis.
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Despite the dissenting views, most scholars still tend towards anaemia as the major interpretation for these lesions
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and point out that, regardless of the diagnosis, healing lesions suggest evidence of the body dealing with pathological environmental pressures.

Interestingly, Bisel did not record cribra orbitalia for the Herculaneum victims but did observe evidence of porotic hyperostosis on cranial vaults of the sample she studied. She interpreted porotic changes that she observed on these skulls as slight, healed anaemia. She considered that it was fairly common in the Herculaneum sample, with an overall frequency of 34.1 per cent (n = 98) as compared to 8 per cent in the modern American sample. She suggested that the most likely cause of the cases of porotic hyperostosis to have been heterozygotic thalassemia. It is worth mentioning the influence of Bisel’s mentor, J. Lawrence Angel, on her interpretations. Angel undertook a considerable amount of work in the Mediterranean region. After World War II he developed a particular interest in palaeopathology and palaeodemography. He published his theories about the development of thalassemia in relation to malaria and was inclined to interpret any evidence that may have reflected anaemia as thalassemia. Bisel conceded that there was considerable controversy surrounding the diagnosis of the different types of anaemia from the skeletal evidence. She, nonetheless, chose to follow Angel’s contention that the best way to determine the type of anaemia encountered should be based on a consideration of the ecological context and the entire population, rather than the appearance of any single individual. This view would not be supported by the majority of palaeopathologists as specific types of anaemia have a unique appearance on the bone. The changes associated with thalassemia are very distinctive; for example, the calvarium, when viewed in section, displays no clear distinction between the inner and outer tables and when examined radiologically, the bone trabeculae resemble the bristles of a brush. Most scholars acknowledge that Angel’s interpretation of porotic hyperostosis in the archaeological skeletal record is probably incorrect and that these bony changes are more consistent with anaemia resulting from nutritional deficiency.
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Unlike Bisel, Capasso recorded 12 cases of cribra orbitalia, along with 12 cases of porotic hyperostosis involving the vaults of the skulls of the Herculaneum sample he studied. Sixteen of these victims were male and seven were identified as female. The frequency of porotic hyperostosis reported by Capasso is about 7.5 per cent, which is considerably lower than that diagnosed by Bisel. In the light of the suggestion that they are different conditions, it is notable that there was only one individual that presented with both disorders.
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Osteophytic changes are bony changes, such as lipping that can be observed on the articular surfaces of bones. They are associated with bone proliferation, most commonly around the joint margin. Contributory factors include various diseases, diet, trauma and advancing age. The two most common types of arthropathies or degenerative diseases linked with osteophytic change are osteophytosis of the spinal column and osteoarthritis of the synovial joints. Osteophytosis involves growth of bone from the margins of the vertebral bodies as a result of the fibrous capsule of the intervertebral discs. Osteoarthritis is non-inflammatory and characterized by bony lipping and spur formation in response to the destruction of the articular cartilage of a joint. These changes are most commonly observed in load bearing joints, most notably the knees, hips and spine.
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In view of the dif ficulty of establishing the cause and kind of osteophytic change from disarticulated skeletal material,
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this study concentrated on the identification of specific arthropathies that could be diagnosed from a minimal number of bones from one individual. The main interest in the identification of arthropathy was to determine what effect it may have had on the ability of individuals to escape and whether there was evidence of any age-related arthropathy that might provide some insight into the Pompeian lifespan. Virtually every different type of articular surface was represented by at least a few examples of osteophytic change of varying degree. The degree of osteophytic change was routinely recorded, using a four-point scale.
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Osteophytic changes were observed in a number of bones. The cases observed in the femur and left humeral sample provide a reasonable indication of the frequency of osteophytic change in the overall long bone sample. A sample of 320 left and right femora in the Forum Bath collection were inspected. Eleven cases of polishing or eburnation, resulting from friction between the articular surfaces as a consequence of destruction of the intervening cartilage, were observed on the distal condyles.
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Osteophytic change in the form of lipping was observed on the heads of some femora.
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It is possible that osteoarthritis may account for the major changes observed on the head of the femur that was also associated with significant shortening of the neck,
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described above in the section on trauma. It is notable that less severe degrees of osteophytic change were not prevalent in the sample.

Marked eburnation was observed on a number of the humeri in the sample, for example on the distal end of seven left bones
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and on the proximal end of one left bone
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in the hundred left humeri in the Forum Bath collection. A lesser degree of osteophytic change was observed on a small number of other bones in the sample.

The only arthropathy that presented in the sample that could be unequivocally identified from disarticulated material was diffuse idiopathic skeletal hyperostosis, also known as DISH or Forestier’s disease. This is because it has a distinctive morphological appearance. DISH is characterized by ossification of the anterior longitudinal ligament, particularly along the right anterolateral aspect of the thoracic vertebrae. This ossification is continuous and has been described as resembling dripping candle wax. It generally affects the thoracic vertebrae. It is usually only diagnosed as present when at least four contiguous vertebrae are fused. The cause of this disorder is unknown but there does appear to be some association with obesity, especially in early life, and diabetes. It occurs more frequently in males and there is a strong correlation between advancing age and the presence of DISH. It is unlikely to be observed in individuals in modern populations who are under fifty years of age.
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Two likely cases of DISH were observed in the Pompeian collection. One case in the Sarno Bath collection is very clear
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and involved four fused thoracic vertebrae. The other
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(Figure 8.9) is more equivocal and comprised a group of two and a group of three fused thoracic vertebrae. These vertebrae were all contiguous; it is possible that there had been at least partial fusion between the groups and that they had been separated as a result of post mortem damage. It is clear that all the bones were involved in the same disease process, with additional bone growth of the same thickness along the