During the past century in progressive countries morbidity and mortality from infectious diseases have changed tremendously (Fig. 3.1). Today, antimicrobials and other forms of treatment interrupt inflammatory processes early and practicing clinicians rarely see the total disease. For this reason, modern clinicians find interpretation of abnormal old bones difficult. Diagnostic acumen in paleopathology is enhanced by experience in medically underserved areas of the world, where twentieth century modalities of health care limited.
In 1925 Moodie noted:
There are two ways in which we may gain knowledge of ancient bacteria. 1. By actual obser- vation of the bacteria or cocci or their spores, in thin sections of rock. 2. By inferring their presence from results which today are due to the action of bacteria (222,p.189).
Subsequently enlightening information has come from studies of mummies and skeletons relating to infections by many different microorganisms (8,62,80,118,246). The possibility of viral disease in mummies was suggested by skin changes attributed to smallpox and skeletal alterations commensurate with poliomyelitis (48,80,206). Although Moodie diagnosed otitis media (middle ear infection) and mastoiditis from radiographs of Peruvian mummies in 1931 (223), in fact, in 1977 Aidan Cockburn still questioned the presence of mastoiditis in antiquity (79b). Until recently little effort was directed toward exploration of changes attributable to more frequent but less dramatic infections, such as the common cold (50,206,311).
Upper Missouri Basin environmental conditions are not conducive to preservation of microorganisms' structure, so Moodie's second approach was adopted as our means for identification of are putative infectious problems. Today, and presumably in the past, most infections involved soft tissue so skeletal residua are few. When skeletal abnormalities were suspected of infectious origin, by comparison with present counterparts, known anatomic specimens, and experimentally produced lesions, supplimented by radiographs and other laboratory techniques, we and others (80, pp.30,32,123,163,287; 364-199), have been able to speculate infecting organism(s) responsible for most unknown lesions.
To promote understanding of what occurs in inflammatory and infectious processes, definition of terms is appropriate.
By definition, inflammation is a localized non-specific biological response to defend, repair, or alter bodily components. It accompanies infections, trauma, neoplasms, physiological stresses, degenerative changes, and certain metabolic disorders. It is triggered by tissue injury to destroy, dilute, or wall off (sequester) stimulating agents and injured structures. Elimination or neutralization of devitalized or intruding elements and repair of the defect are included. The process is similar in all tissues, but is modified by the cause.
In regional dry bones inflammation presented as architectural changes, epiphyseal alterations and periostial reaction, as joint modification, or as contiguous tissue response. Inflammatory processes in skeletons were healed, or arrested at some point in their evolution by death of the affected individual. Undoubtedly many skeletons were involved by inflammatory diseases during life, but for most remodeling during healing eliminated evidence of the process. For this reason, persisting alterations attributable to in flammation represented those of chronic diseases and abnormalities ongoing or recently healed at the time of death. With the disease interrupted before completion, the abnormality appeared as osteitis, periostitis, or osteomyelitis.
We found representation of acute pyogenic (septic, pus forming, or "hot") and granulomatous (chronic or "cold") infections (osteomyelitis). Primary‚ osteomyelitis occurred when microorganisms came to bone from a distant source via the blood stream. When infectious agents entered through open fractures or penetrating wounds, or spread from contiguous tissue infections, secondary‚ osteomyelitis or septic arthritis was a complication. Secondary osteomyelitis was more frequent in adults. When untreated primary or secondary osteomyelitis became chronic, their effect mimicked granulomatous disease.
Bone destruction (osteolysis) accompanied by sequestration of dead bone and varyable but usually vigorous bone production (osteoanagenesis), forming involucra (new bone surrounding sequestra), characterized the clinical and radiographic picture of juvenile pyogenic osteomyelitis. While active, pyogenic osteomyelitis was accompanied by mal-odorous draining sinuses extending from openings in the bone's cortex (cloacae) through soft tissue exiting onto the skin. Juvenile osteomyelitis presented at the ends of long bone shafts (metaphysis) near the epiphyseal (growth) plate. Blood vessel arrangement in growing long bones provides a situation wherein bacteria in the blood stream can lodge and proliferate. Common loci for juvenile osteomyelitis in order of frequency were the femur, tibia, humerus, and radius.
The pathophysiology of juvenile osteomyelitis was discussed elsewhere, making further elaboration unnecessary (246-109;302-60;314-352;364-94). Improved socio-economic conditions and health care techniques have largely eliminated this disease.
Table 3.1. Infection and Inflammation
Site
Skeletons__Culture____Osteomyelitis__Osteitis__Periostitis_______Other_____
Swan Creek
39WW7 Arikara -- -- -- --
N= 82
Mobridge -- -- Tibia --
39WW1 Arikara Tibia
N= 55
Four Bears -- Frontal- -- --
39DW2 Arikara ?Sinusitis
N= 41
DeSpeigler -- -- Fibula --
39RO23 Woodland
N= 50(est)
Ufford -- -- Tibia --
39CL2 Woodland
N= 40
Double Ditch -- -- -- --
32BL18 Mandan?
N= 24(est)
ND Hist. Soc. -- -- -- --
N = 151 Several
Over Coll. Tibia&Fibula Orbital Fibula Mastoiditis
N= 228 Several Fibula Mult.bones* bilateral
Fibula Tibia
Tibia
Tibia**
Misc. Coll. Mastoiditis
& Spec. Several bilateral
_N=_241______________________________________________________________________
Total 912 3 2 9 2
* Femora, prox. tibia & fibula, prox. humerus, distal radii.
** Sabre shin suspect.
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Table 3.2. Infection and Inflammation in Crow Creek Skeletons
Bones
Abnormality__Counted_______________________________________________Total___%___
Osteitis pubis --- --------------------------------------------- 2 ---
Osteomyelitis
Skull 392 (non-lethal scalping) 2 0.5
Tibia 531 2 0.37
Fibula 299 2 0.67
Otitis media* 837 (residua) 322 38.5
Sinusitis
Maxillary 129 1 0.77
Maxillary 129 (with antral-oral fistula) 4 3.1
Abnormal cortex marking (Periostitis)
Adults Sub-adults
Bone Local/ Focal Bone Local/
Bone___________N=__Overall___End___Patchy___Trauma____Overall___End___Patchy__Total___%__
Temporal 963 -- -- -- -- -- -- 5 5 0.5
Occipital --- -- -- 1 -- -- -- -- 1 --
Mandible 131 -- -- -- -- -- -- 1 1 0.7
Maxilla 129 -- -- 2 -- -- -- -- 2 1.5
Palate --- -- -- 1 -- -- -- -- 1 --
Clavicle 233 1 -- 1 -- -- -- 1 3 1.3
Scapula 521 -- -- 1 -- -- -- 1 2 0.38
Humerus 413 -- 3 -- -- 2 1 8 14 3.3
Radius & 206/244 1 1 -- -- -- -- -- 4 1.9
Ulna
Ulna 244 -- -- 2 1 -- -- -- 3 1.2
Ischial --- -- -- 1 -- -- -- -- 1 --
Tuberosity
Femur 734 2 2 4 2 -- 18 4 32 4.3
Tibia 531 20 1 9 18 -- 22 8 78 14.7
Tibia & 513/299 4 -- -- 1 -- -- -- 10 1.9
Fibula
Fibula________299_____8_______--______2_______--__________--_____--_____--_____10____3.3__
Total 36 7 24 22 2 41 28 167
*See Table 3.5 and text.
Adapted from: Zimmerman et al 1980, p. 195.
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caused most often by Staphylococcus aureus. Less frequently the Pneumococcus, Streptococcus, Salmonella (typhoid), and occasionally other microorganisms, were pathogens. Congested living conditions, lack of sanitation, and nutritional depletion predisposed to osteomyelitis (48).
Osteomyelitis caused by granuloma forming organisms was characterized by bone destruction but little repair. If the victim survived, osteoanagenesis accompanied healing. Granulomatous diseases are discussed later.
We know of no accurate information relating to the frequency and severity of bone and joint infections in regional aborigines.
Dental disease including plaque, caries, tooth root abscesses, and alveolar bone resorption secondary to poor oral hygiene, comprised the largest group of infectious problems encountered during the Dry Bones survey. These are discussed in Chapter 9.
Findings attributable to infectious and inflammatory processes in regional skeletal collections are in Table 3.1. The paucity of examples suggests that either few infectious processes involved bone primarily, infectious processes early in life were remodeled during healing such that we did not see residua, or it mirrors Stewart's observation that pathology affects what is found in skeletal collections. Pathological bones are less well preserved, or may not have tantalized opportunistic collectors who sought and kept only unusual specimens (306).
Residua of osteomyelitis were in six bones from Crow Creek skeletons (Table 3.2). These included primary‚ (pyogenic) osteomyelitis in 2/531 (0.38%) tibii and 2/299 (0.67%) fibulae. In 2/392 (0.5%) skulls there were was secondary‚ osteomyelitis complicating non-lethal scalping. Remnants of infection were in 5/129 (3.9%) maxillary sinuses, four with antral-oral fistulae (Ch. 9) (361).
Accentuated periostial markings were on 167 Crow Creek bones, the greatest number on the tibia (83/531, 15.6%), fibula (15/299, 5.0%), femur (32/734, 4.3%), and humerus (14/413, 3.4%) (Table 3.2). Some periostits was interpreted as of metabolic origin, probably a complication of scurvy (Ch. 5).
Table 3.3. Focal Periostitis Larson Site
Cemetery Village
N=621 N=71
Bone_____Total_Partial__N=__Total_Partial_N=_
Clavicle 531 217 1 54 39 -
Humerus 625 267 1 99 44 -
Femur 642 333 1 94 62 -
Tibia 594 327 10 89 42 2
Fibula____500___277____10____66_______59__-__
Total 23 2
Adapted from: Deitrick, 1980, pp. 35-39, 42-44.
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Deitrick recorded 23 instances of localized periostitis attributed to trauma in 13/621 (2.0%) mid-18th century Larson cemetery skeletons, and twice in 1/71 (1.4%) Larson earthlodge (massacre) skeletons (Table 3.3). In both groups of skeletons tibii and fibulae were involved most often. In cemetery skeletons femora, humeri, and clavicles were affected also (Table 2.3). Localized periostitis was in 2/167 (1.2%) skeletons from late 17th century Mobridge MO-1 site, and in 14/242 (5.8%) skeletons from early 18th century MO-2 site (Table 3.4).
Table 3.4. Focal Periostitis Compared
Instances per Site
Site_______________N=___Periost.___%_
Mobridge MO-1 167 2 1.2
1650-1700
Mobridge MO-2 242 14 6.1
1700-1750
Larson Cemetery 628 23 4.1
1750-1785
Larson Village 71 2 3.1
1785
Leaven. Cem. 261 0 0.0
1800-1832
Periost.= # reported for each site.
% = #_Instances_per_site__
# Individuals observed
Adapted from: Deitrick 1980, p. 68.
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Larson and MO-2 were contemporaneous, but MO-1 antedated both. Deitrick did notexplain the greater frequency of periostitis at MO-2 and did not report periostitis in the late (1800- 1832 A.D.) Leavenworth Site skeletons (89(Table 2.5).
Virus infections are common in this region today but they rarely affect the skelton directly. Historically smallpox and measles were highly lethal to the Indians in the Upper Missouri Basin (Ch 1), but they and other past viral diseases left no characteristic osseous changes.
However, viruses that affected the upper respiratory tract did stimulate osseous change indirectly that left indellible marks upon temporal bones, demonstrable as long as they existed. Considerable effort was expended during the Dry Bones project to locate and quantify the indirect effect of viral diseases upon the middle ear and mastoid. The information forthcoming was considerable, and is presented most effectively as suppliment to Chapter 3 (See Ch. 3, Epilogue).
In Figure 3.2 pyogenic osteomyelitis is shown in different locations and stages. The alteration typify osteomyelitis, but similar changes may accompany trauma, aseptic necrosis, or some tumors. In 3.2A a sequestrum is forming. A concomitant defect in the mastoid cortex represented active mastoid disease (Fig. 3.2B). The defects in the mandible and mastoid, and a third defect in the distal humerus could easily have had common origin, acute mandibular osteomyelitis secondary to oral cavity sepsis with contiguous and hematogenous spread (See Ch. 3, Epilogue). If such disease pattern occurred today, infection by Staphylococcus aureus would be likely. The infection appears active and probably contributed to the fatal outcome. Pneumonia or meningitis are possibilities as cause of death.
Figure 3.2C. Bone destruction, sequestration, and involucrum formation in an adolescent distal femur identify pyogenic (juvenile) osteomyelitis, probably active at death (314). The amount of involucrum plus secondary osteoporosis, suggest this process was active for some time, and the bone disease contributed to the individual's death. This was an isolated amateur archaeologist's specimen from near Mobridge, SD. Provenience is unavailable.
Figure 3.2D. Both tibii and one fibula show the end result of chronic osteomyelitis. Openings in the bone cortices (cloacae, arrows) suggest that during life draining sinuses were on both legs. Extensive periostial response indicates that most of the bones' metaphyseal cortices were involved by the infection.
In Figure 3.3 a large, ragged, osteolytic defect is in the left temporal bone. All the mastoid's lateral surface and the contiguous squama are lost. During life the adjacent dura was exposed.
Figure 3.3. 39WW1 Mobridge Site. Arikara male 40-45 yr.
No other abnormality was in the skull or the remainder of the skeleton. This represents ostemyelitis in the mastoid with abscess formation, secondary to acute infection. It could have followed a penetrating wound, but statistically the mastoid is the most likely source for such a process. However, in the absence of previous middle ear disease acute mastoiditis is infrequent in adults (See Ch. 3, Epilogue). Because surrounding bone was destroyed obliterating much regional architecture it was not possible to show with radiographs if underlying ear pathology existed. The vigorous and active destructive process was the portal of entry, and death was due to meningitis, brain abscess, or lateral sinus thrombosis (in fected blood clot), or a combination.
Two Over Collection Arikara skulls had bilateral healed infectious residua involving the mastoids. One, a male age 30-35 yr. was from near Pierre, SD, and the other was a child 4-6 yr. old (39WW7, Swan Creek, #29).
Figure 3.4. 39WW2 Larson cemetery. Arikara female 35 yr. Calvarium, outer surface.
Osteolysis and sequestration but little osteoanagenesis are visible. The appearance of the involved area suggests the effect of non-lethal scalp avulsion some time before death. The large defect in the mid- parietal area surrounded by thin bone is the site previously occupied by a sequestrum, lost as the infectious process eroded into the skull. After the skull's inner table was penetrated, the dura was exposed and infected. Meningitis complicating osteomyelitis explains this woman's death. This and three other skulls from Larson cemetery (4/621, 0.64%) had similar changes in their calvaria outer surface, suggest ing frequent non-lethal scalping in the region at that time (1750-1785) (89). Contrary to common misconceptions, scalping was not lethal per se, scalped individuals were not always dead, and the practice antedated the White Man in North America (Ch. 1) (30,63).
In Figure 7.12 two osteolytic defects are in the midportion of an adult male's hard palate. The defect's edges are slightly irregular with minimal reactive new bone. This defect was originally hypothe sized to be of congenital origin, an abortive palatal cleft (301), but in a personal communication D.R. Brothwell (British Museum of Natural History) disagreed. He asked:
Incidentally, how happy are you about the "cleft palate" case? This surely would be most unusual for a congenital deformity. It is the sort of thing one can find in Leper material, and certainly had it appeared in early British stuff, I'd have thought first of an infective rather than developmental agent.
A treponemal infection must also be considered as cause for the defect (See Ch. 3, Treponematosis). No other similar palatal defects have been recorded in this region.
Figure 3.5. 39WW1 Mobridge Site (1700-1750 A.D.) Arikara male 25-38 yr.
The left scapula's posterior surface is normal, but on the right irregular osseous response is on the scapular spine. This is interpreted as injury to soft tissue overlying the scapula complicated by osteomyelitis. Sliding or dragging abrasive trauma to the back's soft tissue, exposing the scapular spine, is a credible explanation for the findings.
The appearance is that of a vigorous response, indicating infectious activity at the time of death. This wound occurred some time before death and should not have been lethal per se, but it could have contributed to the fatal outcome. There were no other skeletal defects, so this individual must have died of generalized sepsis from this or other soft tissue injury. The wound could have been contaminated during treatment, or have been the portal for concurrent tetanus infection. Because this individual lived in Dakota Territory in the era of the horse (Ch. 1), the possibility of a horse and rider type of accident is good. This contention is supported by Wissler's analysis of the Plains Indians' horseman ship: The young men were trained to bring away their dismounted and dead, reaching down and picking them up by one hand on the run and then dragging them to safety (355-262).
Figure 3.6. 39ST235 Stony Point. Over Collection #3549. Arikara male, 45 yr.
Osteolytic change on the anterior surface of the caudal sacral segments extends from the lateral border to the midline. No reparative response is obvious. Other available skeletal components were normal. Diagnostic considerations include a neoplasm or physical trauma, but this process is best explained as of infectious origin. The most likely infection source is the rectum. Bowel perforation by a sharp foreign object, i.e., a bonefragment, complicated by para rectal abscess, is a mechanism leading to such changes. The paucity of inflammatory reaction suggests three possibilties: 1. the individual succumbed before osseous response occurred; 2. an avirulent microorganism was the pathogen; or 3. it was a granulomatous infection, e.g., tuberculosis. The pelvis is involved by tuberculosis, but this is unlikely here because there was no other bony involvement. Isolated sacral involvement is not a characteristic of this infection (See Ch. 3, Mycotic infections). This is the only such abnormality we have seen.
Septic knee disease was possible in the femur of a skeleton (Fig. 6.14B). This isolated bone was a South Dakota amateur collector's specimen, with out provenience. Other considerations included joint degeneration accruing from long use of an injured knee, or a Charcot joint (joint modification that accompanies spinal cord disease, e.g., syphilis).
Septic arthritis accompanying amputation is a possibility for changes in an adult knee (Fig. 2.16), and humeral head alteration attributed to aseptic necrosis (Fig. 2.24A).
Tuberculosis, leprosy, syphilis, yaws, certain fungi and fungus-like diseases, sarcoid (chronic disease, cause unknown, resembling tuberculosis clinically and histologically), and retained foreign material are the common agents that evoke a granulomatous response. These processes are accompanied by less discomfort and inflammatory reaction than pyogenic infections, and usually develop slowly. Their clinical and radiological appearances vary, but early-on bone destruction is often preponderant. If the acute stage is survived, new bone is produced during healing.
Figure 3.8 A-B. 39WW2 Larson Cemetery. Arikara female 16-18 yr.
Figure 3.8 C-D. 39WW2 Larson Cemetery. Arikara female 16-18 yr.
Figure 3.8 E. 39WW2 Larson Cemetery. Arikara female 16-18 yr.
Photographs show diffuse osteolytic lesions throughout a young woman's skeleton; 3.8A, lower thoracic and lumbar vertebral bodies; 3.8B, medial surface left innominate bone; 3.7C, a rib; 3.8D both distal radii; and 3.8E, proximal tibia. All are characterized by bone destruction and no osteoangenesis. The anterior sacral surface and some tarsal bones were affected similarly.
Many mycobacteria exist in nature, but only three commonly affect man, human tuberculosis (M. tuberculo sis var.hominis - T.B.), bovine tuberculosis (M. bovis), and leprosy (M. leprae). Human T.B. infects lungs primarily but can spread to bone. Bovine T.B. usually enters humans through the intestinal tract, and quite often involves bone.
Tuberculosis is much less frequent in the Upper Missouri Basin today than it was 50 years ago, but active T.B. remains a problem in Aberdeen Area Native Americans (Figure 3.7) (74). Pulmonary infection is most frequent, but scrofula (neck lymph node involvement) and infection in other structures occur occasionally. Skeletal T.B. is unusual in this region today. Bovine T.B. still is a Public Health problem in domestic and of wild animals (83; Blair, R., Secretary of Health for SD, Personal Communication).
The pattern of bone involvment by T.B. in the mid-twentieth century is reflected in statistics from India. There, in 1-2% of tuberculous patients the skeleton is affected. Vertebral infection is commonest, comprising 50% of all skeletal involvement. Next in order of decreasing frequency are the hip, knee, sacroiliac joint, elbow, and ankle (327).
The antiquity of T.B. in the Americas has been conjectural (62-249;246-166;364-8,102). Reasons advanced for believing it did not exist here before the White man arrived include lack of natural reservoirs or hosts for the bacteria (302-170,174), the Bering Straits "cold filter" (305), and nonexistence of the disease before Columbus (225-44). In 1981, as part of a symposium on T.B. in antiquity, convincing evidence was introduced that T.B. antedated Europeans in the Americas. Reports described probable granu lomatous processes in pre-Columbian specimens from several parts of the American continent (64).
Nothing suggesting bone modification by T.B. was found in pre-Columbian Woodland or Crow Creek skeletons from South Dakota.
To assess the epidemiology of T.B. among the Arikara, Palkovich evaluated skeletons from three sites near Mobridge, MO-1 (1700-1750 A.D.), MO-2 (1700-1750 A.D.), and Larson cemetery (1750-1785 A.D.). Data from the 71 Larson earthlodge skeletons were not included. Her findings suggest the MO-2 site antedated MO-1.
Resorptive bone alterations compatible with chronic granulomatous disease were in all sites. In the Larson cemetery 8/621 (1.3%) skeletons had patterns considered typical of skeletal T.B., and two others with possible involvement. At MO-1 there was 1/177 (0.56%) skeleton with resorptive lesions "likely attributable to to tuberculosis", and at MO-2 1/249 (0.4%) individual exhibited serious vertebral and other skeletal involvement. Far more resorptive bone disease was found at Larson than either MO-1 or MO-2, but the mortality patterns for MO-1 and Larson were similar statistically. It was postulated that more individuals died of primary T.B. in MO-1 than Larson, because the people at Larson lived later in history, and a greater proportion of the latter population had acquired immunity to T.B. (253-161).
Skeletal changes in Figure 3.8 characterized by diffuse destruction only, apparently original in lower thoracic and lumbar vertebral bodies, accompanied by resorptive bone disease in the pelvis and elsewhere, are prima facie evidence a fulmanating granulomatous infection (314-686).
Blastomycosis (fungus) or T.B. are possibilities, but because Blastomycosis is not indigenous in South Dakota, T.B. is more likely.
Psoas abscess (Fig. 3.10) complicates Pott's disease and is responsible for the lower abdominal and pelvic findings in Figure 3.8A, 3.8B, and the skeleton's sacrum. Granulomatous infections involve primarily the vertebral centrum (body) forming abscesses that rupture through the anterior longitudinal ligament of the spine into the psoas muscle space. The infection spreads into the lower abdomen and pelvis posteriorly, where it affects many structures. The abscess focuses in one or more locations, unilaterally or bilaterally, and drains by rupturing through soft tissue and skin. Common places for psoas abscesses rupture are: 1) through the sciatic notch (III); 2) near the femoral greater trochanter(IV); 3) between the pubic bone and the inguinal ligament (V).
The vertebral and pelvic disease illustrated in Figure 3.8 typifies classical Pott's disease, psoas muscle abscess formation, and migration of the infection into the pelvis, and beyond. The extensive involvement of more distant parts of the skeleton indicates hematogenous dissemination of the infection throughout the victim's body. Death in this instance was from overwhelming general sepsis, with pulmonary or central nervous system complications being its most likely cause. Had this individual survived, the affected vertebrae would have collapsed with the resultant hunch back deformity. In addition, after vertebral collapse she would very likely been paralyzed in the lower part of her body due to spinal cord compression.
Recognized human Treponema (spirochete) pathogens syphilis, yaws, bejel, and pinta. All but pinta infect bone. Syphilis is worldwide, yaws is restricted to the tropics, and bejel exists mostly in Syria and Iraq (207-73). Many references to Treponematosis in the literature center on whether syphilis was indigenous to the Americas or whether it came from Europe (84,117,202,206,338,339). The four pathogens may all be the same microorganism, altered by cultural passage (71;256-180;307;346-96). Syphilis involves all structures of the human body and its effect has many forms. As the result, in the past syphilis was nicknamed 'the great imitator' (299-505). Treponema must always be considered when unusual lesions appear in old bones.
Early syphilitic bone infection is usually periostitis, two clinical manifestations being periostial nodes and diffuse osteitis. Syphilitic osteitis is acquired or congenital, and bone can be involved in early or late stages. In the late stage, gumma (granuloma) formation is more likely.
Figure 3.11A. 39BF11 Crow Creek. Proto-Arikara male adult. Tibia and fibula, anterior view.
Figure 3.11B. Antero-posterior radiograph.
Syphilis differs from tuberculosis in that it affects the mid-shaft (diaphysis) of long bones but seldom involves joints, and it evokes osteosclerosis rather than osteoporosis. Bones affected most commonly are the tibia, sternum, cranium, and facial bones, especially the nose and palate. Steinbock summarized the paleopathological aspects of treponema infections (302-86), and he and others discussed effects of treponema upon the human skeleton (246-180;329).
Historically, venereal disease was prevalent in North America (71;79;84;202;335-94,152,210;338;339;340) and the Upper Missouri River Basin (77-43,311;90) quite early. Nothing suggesting treponemal infections was in Middle Plains Woodland skeletons, but periostitis with several configurations involved 167 bones in the Crow Creek skeletons. Tibii were affected most often (88/531, 16.6%) followed by the fibula (20/299, 6.7%), femur (32/734, 4.4%) and the humerus (14/413 3.4%). On ten occasions skull and facial bones had periostitis (Table 3.2). Some tibial periostitis could have been of traumatic origin (Ch. 2, subperiostial hematoma), some were secondary to nutritional depletion (Ch.5, scurvy), but in a number cortical modifications were atypical, suggesting non-pyogenic disease (361).
In Figure 3.11A periostial reaction affects both bones in a tibia fibula articulation. Except for the articular surfaces, the entire tibia is involved extensively, but reaction on the fibula is limited (arrow). Areas of breakdown are visible in several places on the tibial surface, but in the gross specimen the reaction was atypical. This specimen's radiograph (Fig. 3.11B lower) is compared with another Crow Creek adult tibia with severe periostitis and osteosclerosis. In both, extensive osteitis involves all portions of the bone, except articular areas. The reaction on the bones' surfaces suggests strong periostial stimulation, such as that produced by treponema. In the lateral view this tibia is definitely anterior-bowed, giving a "sabre shin" configuration. These were disarticulated bones, so it was not possible to seek concomitant pathology. Other Crow Creek bones had similar periostitis and osteitis.
Finding this type reaction in Crow Creek was of interest doubly. The pathology suggests the effect of yaws or syphilis, but the Upper Missouri Basin is not endemic for yaws. Second, Crow Creek Site carbon-dating placed the massacre in the mid-14th century, indicating pre-Columbian origin for the abnormality.
To evaluate by modern laboratory methods whether changes in the Crow Creek villagers' bones could have been caused by treponema, an attempt was made by Marvin Allison (Pathology Department, Medical College of Virginia) to demonstrate anantibody response. A solution prepared from fragments of three different affected bones was injected into three rabbits, successively. Unfortunately, the bone fragments were contaminated by soil bacteria (clostridium) that killed the rabbits before a serological titre could be inducedin their immune system.
For this reason, it was not possible to confirm by current serological techniques that an antibody titre to treponematosis had existed in14th century mid-America. Inconclusive serological testing notwithstanding, the 'clinical' and radiographic findings strongly suggest the effects of Treponematosis (129).
Other examples of periostitis having several configurations have been observed in various bones representing different cultures and periods in time in this region. At least some of these may represent the effects of treponemal infections.
The distal portion and articular surface of an isolated adult femur (Fig. 6.14B), a South Dakota collector's specimen (provenience minimal), was involved in a severe inflammatory process that ended in marked degenerative joint disease (hypertropic arthritis). This might been from septic arthritis, or from old joint trauma. It could also have been a Charcot joint (neurotropic arthropathy), due to use of an injured joint by an individual with sensory impairment. Central nervous system syphilis is one cause (See Ch. 3, Pyogenic Arthritis, and Ch. 6).
Despite periostitis suggesting treponemal infection, no gumma or pericranial involvement was observed. A Larson cemetery female skull's outer surface had extensive remodeling (Fig.3.4), that during preliminary evaluation at the University of Tennessee Arthropology Osteology Laboratory was considered of syphilitic origin (C.S. Smith, Personal communication 1973). This hypothesis was invalidated when traumatic origin by non-lethal scalp avulsion was proven.
Notched maxillary central incisor teeth, suggesting Hutchinsonian teeth (dental changes due to congenital syphilis), were in a North Dakota child's skull, but the skeleton had no other defects. (J. Williams, Anthropology Laboratory, University of North Dakota, Grand Forks. Personal communication, 1985). Willey and Swegle reported a South Dakota Sioux child's skull with notched teeth, for which congenital syphilis was suspected, but abandoned after expert consultation (See Ch 9) (350).
Without histological or microbiological confirmation diagnostic classification was tenuous for two unusual South Dakota skulls (141). The osteological patterns in evidence suggested residua of infectious diseases, probably granulomatous type, with the disease processes probably contributory to the fatal outcome. Our interpretation of these specimens was based largely on clinical observations and experiences during examination and treatment of patients in this region.
In Figure 3.12 the entire right hemi-face was by an extremely destructive process that involved all tissues. Faint periostial reaction has occurred on the frontal bone and in the right maxilla superior to the alveolar process. Maxillary teeth are worn; the right canine tooth was lost antemortem; the first premolar root is involved in the process. An incidental finding is nasal septal deformity causing moderate airway obstruction. Other skeletal components were normal.
Diagnostic considerations for Figure 3.12 include a neoplasm in the facial structures (rare in con temporary regional Indians), dental disease (Fig. 3.13A), physical trauma with pyogenic infection (Fig. 3.13B), or paranasal sinus disease.
Figure 3.12. 39SL4 Sully Site (9634). Arikara male 40+ yr.
The location and finding of an extensive locally invasive process within which tissue destruction is preponderant and repair is minimal, direct suspicion toward granulomatous disease, Actinomycosis being an excellent possibility (141). In 51% of all cases Actinomycosis invades the human body in the cervico-facial region (276), affects all structures, produces severe local tissue destruction, and excites little reparative response. Actinomycosis is prevalent throughout North America but is more common in agricultural settings, especially around cattle.
In the paleopathology literature Actinomycosis was suggested as a differential diagnosis (175- 61;302-179;302-208), and Alexandersen cited one instance from France of possible Actinomycosis involving the maxilla and mandible (6).
An isolated calvarium was found close to an old Indian village site near the Missouri River in mid-South Dakota (Fig. 3.14). Multiple round, punched out defects 5-8 mm in diameter involved the skull's three tables, some apparently active and others with osteosclerotic edges suggesting older lesions (3.14A,B,C,E). Other defects were in the outer cortex only (3.14D) and the left supraorbital plate (3.14G). The process was osteolytic with only token osteoanagenesis. Proliferative vascular response was on the right parietal bone's medial surface (3.14B). Widened diploic space and thinning of the cortices (3.14F) suggested concomitant intramedullary pathology. In radiographs (3.14H,I) some lytic lesions had discrete borders, others were indistinct with satellites. Sclerosis surrounding the lesions varied; where greatest it extended 1.0 cm. from the lesion's edge. The different types and stages of lesions in this skull indicate the process was active for sometime, and the host bone was responding protectively only slightly.
Figure 3.14 H, I. Radiographs of calvarium
Possibilities for pathology illustrated include metastases from a neoplasm, e.g., multiple myeloma or other primary cancer, or a granulomatous process such as T.B. or a mycotic infection. We consider T.B. unlikely. Blastomycosis could produce such lesions, but it is prevalent primarily in south eastern U.S. (276).
This specimen was reviewed at The Armed Forces Institute of Pathology by Ellis Kerley (1960) and Vincent Hyams (1980) (Personnal communique). These evaluations supported but did not amplify comments above.
Two mycotic infections that have predilection for the skull and must be considered are Coccidioido mycosis and Cryptococcosis. The former produces similar skull lesions, but the diseaseis endemic only in southwestern United States (254). Although this individual could have migrated to this region, this is considered unlikely.
Toone and Kelly analyzed clinical and radiographic information pertaining to mycotic bone and joint disease, and presented the findings in a patient with Cryptococcosis (323). Their patient's radiographs were identical with radiographs in Figure 3.14H,I.
Cryptococcosis, infection by a widely distributed yeast like organism, has predilection for the central nervous system. Osseous involvement occurs in 10% of cases and is a chronic, destructive, slow process that appears most often in the vertebrae and cranium. Bone destruction includes both cortical and cancellous portions with little tendency for repair. In the living person soft tissue overlying bony lesions breaks down to form draining sinuses, similar to pyogenic osteomyelitis. The radiographic appearance is that of well demarcated osteolytic defects surrounded by a zone of dense bone (276).
Steinbock listed Torulosis (Cryptococcosis) in differential diagnosis but reported no dry bone specimens (302-204), and Ortner and Putschar mentioned but did not illustrate Cryptococcosis (246-224). We believe the findings in this specimen are most likely the result of a granulomatous infection, Cryptococcosis being the best possibility.
Figure 3.15. 39SL4 Sully Site. Arikara male adult.
A flint fragment embedded in the distal fibula is probably the tip of a projectile that penetrated, broke off, then was encased by fibrous tissue and bone. Penetrating foreign objects usually carry microorgan isms into wounds, so the likelihood of infection was considerable. Two methods to handle foreign material or penetrating microorganisms are extrusion or encystment. The reaction here indicates the object was walled off, encapsulated, and incorporated into the affected tissues. Nothing suggests infectious activity at death. The clinical and histological response with encapsulated foreign material resembles granulo matous infections. Other examples of foreign particles in bone are in Chapters 1, 2, and 4.
NASAL TURBINATE HYPERTROPHY. Allergy ?
Figure 3.16. 39SL4 Sully Site, Arikara female 35 yr.
Middle turbinate bones, especially in the left are enlarged, alerting the Ear, Nose, and Throat physician that allergy must be considered. Incidentally, the bony nasal septum is thickened and warped. During life the combined abnormal septum and enlarged middle turbinates compromised the nasal airways. The findings are postulated as those accompanying seasonal hay fever or allergic rhinitis. As such, nasal mucous mem brane changes might have been accompanied by nasal polyps. In addition, in this individual the possibility of concomitant asthma would have been excellent.
Although allergic rhinitis cannot be proven in dry bones, the findings in this skull are tantaliz ing. Enlarged turbinates have been observed in other skulls from this region, suggesting that nasal airway problems, possibly of allergic origin, were not unknown to the former Upper Missouri River Basin inhabitants.
Allergy is part of the human immunological response, and can mimic the inflammatory reaction accompanying infections. It most frequently involves the lungs, upper respiratory passages, and skin. In this region today nasal allergy problems occur with approximately the same frequency in Native Americans as in the general population.
Historical references to asthma are summarized in Brothwell and Sandison (62-214,492). Vogel referred to use of herbs and other remedies by North American aborigines to treat asthma (335-336,368). Generally, allergic disease in antiquity has not been explored by paleopathologists.
OTOSCLEROSIS.
Investigations and findings during the Dry Bones survey relating to otosclerosis, an inflammatory process involving the middle and inner ear, are in Chapter 3, (Epilogue).
AUDITORY CANAL CHOLESTEATOMA.
Stewart alluded to the possibility of external auditory canal cholesteatoma in adult skulls. This would have been manifest as erosion of the tympanic plate, leaving a defect resembling the foramen of Hushke in childhood (307) (Ch. 4, Epilogue). In clinical practice this abnormality has been observed occasionally, with the same frequency in the general and Native American populations. Dehiscence of the tympanic plate, suggesting canal cholesteatomata has been observed on several occasions in adult aboriginal skulls. Unfortunately, in dry skulls there is no way to differentiate canal cholesteatomata from develop mentally patent foramen of Hushke.
During the interval 1900-1968, the pattern of diseases in a large portion of the globe changed more than it had in many millennia (Table I.1, Fig. 3.1). Prior to and in 1900 in the U.S. six of the the ten most common causes of death were infections, but in 1968 only one infection, influenza and pneumonia, remained in the top ten. Only one infection in the 1900 top ten lethal diseases, T.B., had significant potential to involve bone. The ancient scourge that destroyed many people worldwide and much of the native population of this region, smallpox, has recently been declared eradicated from the Earth. A number of factors including immunizations, sanitation, better nutrition and improved socioeconomic conditions, the antimicrobial drugs, and education, have influenced the overall change in infectious disease patterns. In the past and at present infectious diseases usually have greatest effect upon soft tissue. Other than infectious dental disease primary skeletal infections are not common in this region today.
Infections still play an important role in the lives of Missouri River Basin inhabitants, moreso on Indian reservations where health care facilities are often limited. Mortality and morbidity in the Indians attributable to infectious diseases have decreased steadily, but they remain problems, and their pat terns are reminiscent of ancestral patterns (Fig. 3.17) (74).
Because documentation is lacking, the infectious diseases in pre-White contact American aborigines have been enigmatic (77-49). European immigrants were blamed for many problems in post-1492 A.D. American Indians, particularly for bringing infectious diseases (24).
After having had the opportunity to evaluate the remnants of many pre and post-Columbian inhabitants of this region and having had access to anatomical specimens and statistical studies by others, it is apparent to us that at least some of the blame cast upon European invaders is of questionable merit.
As with any isolated population, the pre-Columbian American Indians should have had individual and communal immunity to indigenous infections. Historically, contagious microorganisms from afar overwhelmed the natives' immunity and surmounted existing health care practices. Smallpox and measles were especially devastating in this region.
Communicable human infectious, especially those caused by viruses, depend upon susceptible hosts to replicate and survive. When the host dies, the infectious agent dies. If the victim survives, some degree of immunity usually persists. In civilizations with high population density, or where there is frequent commerce between groups of people, communicable infections can persist through the availability of susceptible individuals. The reverse is true in populations isolated by geography or other factors. In isolated groups of people contagious diseases are introduced from outside and the pattern is one of periodic outbreaks. Survivors of an epidemic live and procreate. Later the new non-immune generation is affected when the infectious agent returns (50;97-33;217-92;237;290-93). Based on headcounts, winter counts, and information supplied by past travelers, Upper Missouri Basin epidemics occurred about every 16-20 years, the interval necessary for a non-immune generation to grow up (290-93).
Despite determined efforts to uncover osteological evidence of smallpox by direct examination and with radiographs, nothing diagnostic was found in Arikara or other regional culture skeletons.
Jacks described alterations attributed to osteomyelitis variolosa (smallpox) in 1/373 skeletons from an Ontario Neutral Indian cemetery dated to just before A.D. 1650. Fe 1/33, an adult male, had osteolytic changes in the hip, femora, and elbows. The left elbow was most severely involved with destruction of the three bones and diffuse atrophy of disuse. The affected individual survived with at least two malfunctioning diarthrodial joints. Technical difficulties precluded Jackes in-depth investigation, but she regards this as the first recognition of smallpox in an archaeological context (173).
Historically, gastroenteritis, diarrhea, pneumonia, and upper respiratory infections, were devastating to children in this region (90), but they also left no identification in bone. Epidemiological patterns derived from cemetery populations antedating historical corroboration reflect mortality and morbidity associated with childhood infectious diseases (Ch. 8).
During the Dry Bones research it was obvious to us that during the time span represented, areawide healing practices were adequate for treatment of uncomplicated adult infectious diseases. For the most part residua of infectious diseases here were comparable with findings in similar skeletal populations.
Findings during the Dry Bones survey are in accordance with Birkett that osteomyelitis was not a common disease. Birkett questioned the prevalence of osteomyelitis in antiquity. He indicated that it never was a common disease, but it has received attention in paleopathology reports because of its dramatic physical manifestations and its relatively easy diagnosis. He cited reports giving variable but low frequencies of occurrance (0-5%) for this disease in skeletal populations. In addition, he noted that osteomyelitis has been found more often in medieval and modern populations, attributed to crowded living conditions and nutritional depletion (48-100).
Periostitis has presented as several patterns and in different anatomic sites. Severe periostitis, strongly suggesting the effects of syphilis, was found in pre-1492 A.D. Crow Creek skeletons, but technical difficulties precluded verification of "clinical" and radiographic impressions by modern serological methods.
Probable pre-Columbian T.B. has been reported from other parts of the Americas (8,64,200,338,339, J. Williams, Anthropology Department, U. North Dakota, Grand Forks, Personal communication), but we saw no osseous changes attributable to granulomatous infections in well over 600 pre-Columbian skeletons. Definite evidence was foundin those who lived later.
The fact that granulomatous bone disease attributable to T.B. was not identified in pre-Columbian skeletons during the Dry Bones survey does not imply it is believed it could not have existed. If indeed it existed, the number of instances was undoubtedly small and infection by the bovine bacillus would have been most likely. This type affects other animals and is transmittable to humans, usually entering through the gastrointestinal tract. Human type T.B. usually enters through the lungs. Tuberculosis is a disease of crowded living environment and close personal contact between disease carrier and victim.
The pre-Arikara cultures were primarily hunter-gatherers and probably separated into small bands. Lack of close inter-personal contact may have been the important element preventing the appearance of T.B. in these people. Unfortunately, no cemetery skeletons were available from Crow Creek for comparison with the massacre population. The Crow Creek people are believed to have been fore-runners of the Arikara. The presence of non-pyogenic infectious bone disease in skeletons from a cemetery could have done much to establish the antiquity of T.B. in this region.
The agrarian Arikara and Mandan cultures, living in earthlodges containing up to 30 people each, clustered in compact villages, provided an excellent millieu for the propagation of T.B. and other commu nicable diseases. In addition, Arikara mores (90-53) and hygiene (90-52) were important factors influencing the dissemination of infectious lung disease.
A reason used by others to explain the absence of T.B. from pre-1492 A.D. America is that there were no natural vectors or carriers. Relating to reservoirs for this disease in the New World, Steinbock opined, "Bovine tuberculosis does not infect wild animals, but only those thathave been domesticated" (302-170). Contrariwise, many animal hosts for this infection existed in the Upper Missouri River Basin, the badger, garter and rattlesnake, buffalo, elk, moose, deer, opossum, ground squirrels, and brown rat (23,53,100,148,185,229,270,354).
Regional paleo-epidemiological patterns for osseous changes resembling T.B. and syphilis, based upon anatomic modifications in evidence, had to be interpreted cautiously. What presented in skeletons represented only a portion of the infected. In modern India where tuberculosis is common, only 1-2% of all tubercular patients have bone involvement (327). In untreated individuals spontaneous cure of syphilis occurs in 33%; another 1/3 develop serological changes but no late stage manifestations; 1/3 progress to tertiary disease (277).
Upper Missouri River Basin Dry Bones osteological findings are at variance with or do not corroborate certain observations by others.
CATLIN
After traveling through the Upper Missouri River region George Catlin (72) reported regarding hunch back:
Amongst two millions of these wild people whom I have visited, I never saw or heard of a hunch back (crooked spine), though my inquiries, were made in every tribe; nor did I ever see an idiot or lunatic amongst them, though I heard of some three or four during my travels, and perhaps as many deaf and dumb.
Hunch back frequently follows spinal trauma, but it also can be secondary to congenital
abnormalities, or may accompany osteoporosis (Ch. 1, Ch6). In Catlin's time granulomatous
infections involving the spine were a potential cause of this deformity. Vertebral
infectious disease and collapse secondary to trauma and osteoporosis were present in
regional skeletons that antedated, were contemporaneous with, and that existed afte
Catlin's visit. Possibly Catlin did not visit villages inhabited by affected individuals,
missed them during his travels, or received erroneou information from informants.
T.D. STEWART stated:
In 1960 I advanced the idea that the acute diseases known to us today might have been left behind by the First Americans during their passage from Asia through the Far North (Stewart 1960). To account for this I likened the Far North to a "cold filter." Although the cold does seem to play a role in inhibiting the spread of disease, I am not sure now that it alone accounts for the failure of the Old World diseases to reach America prior to 1492 (cf. Stewart 1974). Were the presently known acute diseases in existence in the Old World at the time of the first peopling of America? Migrating people cannot leave behind something that has not yet come into existence (307).
F. BLACK postulated:
Diseases that affect only man fall into two distinct catagories. Those which can persist in an individual for a long period are highly endemic, but those which are infectious only in the acute phase die out quickly after introduction. The suggestion is made that the latter diseases could not perpetuate themselves before the advent of advanced cultures and did not exert selective pressures on the human genetic constitution until relatively recently (50).
W. SWINTON observed:
Certainly modern diseases such as measles, mumps, cholera, and the common cold, which require large concentrated populations to support them, probably would not for this reason have existed in prehistoric times (311-55).
K. MANCHESTER stated:
The infectious diseases due to viruses are in different class since at present no universal, totally effective antiviral agent exists. The diseases of the common cold, influenza, measles and smallpox for example are incurable once established. Success against them depends upon preventing their establish ment. With very few exceptions, however, these viral diseases are not manifest in palaeopathological material and for this reason will not be discussed further (206-13).
V. VOGEL reported:
Indeed, those who led this strenuous life were not immune from all ailments, but it appears that they were spared from most of the infections and deficiency diseases (335-161).
Contrary to others' opinions regarding the antiquity of many infections, we interpret findings in Dakota Territory skeletons to indicate that throughout the time interval represented, inhabitants of this region were troubled by different infections that included upper respiratory infections and their complications. This conclusion is based upon demographic profiles for longevity in Upper Missouri Basin aboriginal villages that indicate high neonatal, infant and childhood death rates, mirroring the effect of infections upon the populace (Ch. 8), and findings in mastoid radiographs indicating the effect of otitis media during the time in life the mastoids are developing (Ch. 3, Epilogue).
Factors contributing to the lethality of infections in children included rigorous Dakota Territory winters, crowded living conditions in smoky earthlodges, periodic nutritional depletion, and gastroenteric infections and possibly infestations.
As known today and as it probably was in the past, otitis media begins in the nose and throat as upper respiratory infections that invade the middle ear through the eustachian tube. Changes persisting in mastoid air cell patterns in old skulls provided an indellible index of not only the presence of respiratory infections and otitis media, but also some indication as to approximately the point in life they occurred (140). Upper respiratory infections do not always involve the ear, and otitis media can occur but subside without inducing mastoid changes, so the temporal bones findings attributable to previous otitis media provide only a minimum estimate of the upper respiratory infections affected people endured.
In addition, complications of otitis media including cholesteatoma and brain abscess or meningitis, were present or possible in ears of people who lived 600-1200 years ago. Such findings convince us that individuals in this region lived with smoldering ear infections for extended intervals, and very likely had impaired hearing in affected ears.
It is impossible to know exactly what microorganisms infected the respiratory mucous membranes of people who lived here in the distant past, but it can be stated catagorically that organisms in existence throughout the millennium behaved similarly to those causing otitis media today. It is notable that mastoid air cell patterns indicated more effect of otitis media in individuals who lived in this region post-1492 A.D. This could represent the activity of new microorganisms from Europe.
The foundation for the Dry Bones investigations was laid in North Dakota and South Dakota in the mid 1950s. During Ear, Nose, and Throat Clinics on Indian reservations middle ear disease (otitis media) and its complications were common in contemporary Indian people, and apparently more frequent in the Indians than in the general population (124). The early findings stimulated interest in regional epidemiology, and later in paleopathology, culminating in the Wet Bones and later the Dry Bones projects. Subsequently, demographic studies reflected similar patterns in contemporary Native Americans elsewhere in the United States, Canada, and Alaska (58,67,365).
The obvious question that evolved from clinical experience concerned whether the high frequency of otitis media was something new, whether it was the result of better reporting at Indian health facilities, or was it due to other factors such as: 1. poor utilization of health care facilities by Indians; 2. substandard living environment; 3. different cultural attitudes in that many Indians believed draining ears were merely apart of growing up (210); 4. lesser resistance to microorganisms responsible for otitis media; or 5. perhaps an anatomic difference in the formation or the function of the Indian eustachian tube, the pathway through which microorganismsreach the middle ear.
A study was prepared to resolve question # 5 by examining histologically the eustachian tube middle ear complex of fetuses aborted in South Dakota. For cultural and logistical reason it did not come to fruition.
To assess the prevalence of otitis media and principal complication, hearing loss, large scale otological and hearing and speech studies were performed on children at North and South Dakota Indian reservations. Control studies were done on children from the general population (Wet Bones Project). Active ear disease, residua of otitis media, and hearing losses were frequent findings, but were more common and more severe in Indians. The amount and severity of middle ear pathology varied noticeably between reservations. There was was less active and residual middle ear disease in Indians who had progressed farthest from the aboriginal state (124,273). This investigation and others demonstrated that otitis media was the commonest infection in the northern Great Plains area, secondary only to the "common cold" (74,138). The antibiotics had not erased disease as hoped, merely changed the patterns (see Figure 3.17).
Otitis media is primarily a disease of Winter. It begins with upper respiratory infections that spread to the middle ear. Immunological immaturity, adenoid and tonsil hypertrophy, and infantile eustachian tubes predispose to otitis media. Typically, respiratory infections, and otitis media, follow a three-stage pattern:
Respiratory infections' predilection for Winter is related to upper airway mucous membrane (mucociliary) function. The membrane's integrity is influenced by ambient temperature, humidity, and respiratory irritants such as smoke, in the living environment. They are common in children, but decrease in frequency and severity during maturation through anatomical, physiological, and immunological changes paralleling growth (Fig. 3.18). The human immune mechanism is usually well developed and resistance to respiratory infections is at the adult level by the mid-teens. Acute otitis media without antecedent childhood ear disease has not been common in clinical practice in this region.
Figure 3.18. Otitis media by age, CY 1976.
Figure 3.19. 39ST1 Cheyenne River Site. Over Collection. Arikara male 30 yr.
DRY BONES MASTOID SURVEY
The fact that the temporal bones are resistant to weathering enhanced the study of ear diseases in an tiquity tremendously. Added to this was the large number of temporal bones available for examination. The temporal bone count was the most accurate indicator of the number of people represented in the Crow Creek mass grave.
The mastoid portion of the temporal bone is semi-solid (diploic) originally. It becomes porous (pneumatized) by ingrowth of the mucous membrane from the middle ear, beginning shortly before birth. By age 4-5 yr. the air cell system is usually developed but pneumatization continues until the teens.
Otitis media during mastoid growth can alter pneumatization, leaving indellible changes identifiable as long as the temporal bone exists. Not all episodes of otitis media lead to diagnostic changes, howev er. It is possible to have otitis media but still have normal mastoid radiographs.
In 1964, to investigate the antiquity of ear diseases in South Dakota, 221 W.H. Over Museum skulls were examined grossly and with radio graphs. Law (lateral) and Stenvers (posterior-anterior) views were taken of each temporal bone. Radiographs were interpreted: 1. Pneumatic‚ (well developed air cells showing no alterations attributable to otitis media). 2. Diploic‚ (no pneumatization of the mastoid, implying repetitious otitis media early in life). 3. Mixed‚ pneumatic and diploic (otitis media sufficient to alter pneumatization after it started). and 4. Sclerotic‚ (dense mastoid indicating injury by otitis media) (325).
In Figure 3.19 the left temporal bone is well developed and radiographs show good pneumatization. The lateral view (middle photograph) and antero-posterior projection (bottom) show a normal mastoid.
The Over Collection skulls were heterogeneous in culture and time, but it was possible to conclude that middle ear infections affected a significant number of individuals represented by the skulls (134,142).
Because of the Over Collection's heterogeneity and preponderance of adult skeletons, (indicating a skewed population) the mastoid survey was expanded to include radiographs of Sully Site (homogeneous 18th century Arikara population with all ages and both sexes) and U.S. National Museum Dakota Territory (heterogeneous in age, sex, time, and geography) skulls. Later, radiographs of Crow Creek temporal bones were accessioned. For comparison, radiographs of modern populations were obtained at the Pierre, SD. Indian School and the Veterans Administration Hospital, Sioux Falls, S.D.
Our interpretation of the mastoid radiograph survey is in Table 3.5 (140). Radiographs of 148/385 children at the Pierre Indian School (homogeneous Sioux, grades Kindergarten through 12) are contempora neous controls for the Dry Bones studies.
Notably, there were fewer mastoids with disturbed air cell patterns in Crow Creek skulls than in other old temporal bones, and a similarity of findings between Crow Creek mastoids and present day Indian children.
Table 3.5. Mastoid Air Cell Development in Temporal Bone Radiographs
Source____________N=____Pneumatic__%__Sclerotic__%__Mixed___%__Atypical*__%__
W.H. Over** 417 220 53.0 26 6.0 157 38.0 14 3.0
Museum
Crow Creek 837 516 61.5 26 3.0 242 29.0 53 7.0
(Proto-Arikara)
Sully Site *** 255 116 45.5 12 4.5 92 36.0 35 14.0
U.S. National 257 128 50.0 8 3.1 67 26.0 54 21.0
Museum (Sioux)
Pierre_School#___296_______210___71.0_____9_____3.0___35__12.0___42_____14.0__
Overall 2,062 1,190 57.7 81 3.9 593 28.7 198 9.6
* Includes mastoids with diploic configuration.
** Collection heterogeneous in age, sex, culture, time and geography. Fifty
skulls (88 temporal bones) were Middle Plains Woodland; 4 sclerotic, 33
mixed, 1 diploic. *** A homogeneous population with all ages and both sexes.
# Children at Indian School located near Pierre, SD, 1962-64.
Adapted from: Gregg & Steele 1982.
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Crow Creek villagers ante-dated White contact and were not exposed toEuropean herd-type diseases, so apparently they had fewer or less virulent respiratory infections than those who lived later. The smaller amount of mas toid alteration in the Pierre children, despite the fact that otitis media is their commonest infection today, probably reflects better socio-economic conditions.
It is interesting that the number of sclerotic mastoids was similar in all temporal bone groups, despite tremendous differences in time, culture, and socio-economic conditions. A second significant finding is that the frequency of mixed type mastoids varied considerably during the past 1,000 years, but is lowest in today's Indian children. This is interpreted to mean that despite the fact otitis media is still prevalent, it does not affect mastoid pneumatization as much as it did in the past (140,142).
COMPLICATIONS of Otitis Media. Cholesteatoma.
In Figure 3.21 the right mastoid was grossly normal, but the left was small. The posterior superior external auditory canal was thin (arrow). In the area of the aditus (opening) into the mastoid the bone was eroded, indicating the effect of a cholesteatoma (an expanding mass of epithelial debris [dead skin] that often forms in a chronically infected ear). The underdeveloped mastoid combined with posterior canal erosion indicate long standing infection, probably dating to early life. Radiographs showed erosion of the ear canal and mixed type pneumatization bilaterally, more pronounced on the left. In such ears there is good likelihood the hearing was impaired.
Figure 3.21. U.S. National Museum 325 419 Hrdlicka Collection. Arikara male, 40-45 yr.
Defects due to cholesteatoma were in two Crow Creek temporal bones radiographs. In 3.22 (lower) a Stenvers view radiograph shows a round defect in the superior portion of the middle ear attributable to cholesteatoma (>C). For comparison, the upper is normal.
Figure 3.22. 39BF11 Crow Creek. Pre-1492 A.D. Proto-Arikara, adult.
Two examples of this sequel to otitis media this group of skulls indicates that complicated chronic ear disease existed in the region in the mid-14th century A.D. Evidence of cholesteatoma has been in other skulls from different cultures and periods in time. Such findings are ear-marks of chronic suppura tive otitis media. Cholesteatomata erode intracranially through the roof of the middle ear (tegmen tympani), so meningitis and brain abscess were potential complications also. Furthermore, it is likely that a number of regional natives had impaired hearing in one or both ears during life.
OTITIS MEDIA, Indicating Respiratory Infections.
Otitis media and its sequellae and complications begin as upper respiratory infections, so mastoid changes attributable to it provide a rough indicator of the prevalence of upper respiratory infections in the population. Inasmuch as the mastoid is usually quite well pneumatized by the 4-5th year, but air cell development continues into young adulthood, alterations can be an index of the frequency of otitis media, and a rough indicator of the time in life infections occurred.
An additional observation emanating from the Dry Bones mastoid radiograph study relates to the microbiological flora in this region in antiquity. Although no specific microorganisms can be identified, it can be stated categorically that infectious agents that behaved in a fashion similar to those prevalent today have affected individuals living in this region during the entire past millennium (140). Research reports indicate that otitis media, mastoiditis, and their complications, were prevalent elsewhere in the past (223,271,320,321).
OTOSCLEROSIS.
Otosclerosis is an inflammatory disease involving the temporal bone, particularly the capsule surrounding the inner ear structures. In its early stage this process is characterized by soft vascular bone (otospongiosis), but as the disease progresses the bone becomes hard (sclerotic). Otosclerosis affects the otic capsule of 1:100 individuals in the U.S. today, but only 1:10 of these have impaired hearing (146). When the stapes footplate is involved a conductive type hearing loss is frequent. Hearing loss due to stapes fixation occurs more in females and usually appears between 15-35 years. In the past many factors, including otitis media, were implicated as cause for otosclerosis (165,166). Now infections are not accepted as being influential (140).
During clinical studies of adult and sub-adult Dakota Territory Native Americans, hearing losses were frequent (124,134,138,328), but deafness attributable to otosclerosis was not observed. In other clinical studies this disease was not evident in genetically uncontaminated North or South American Indians (315).
The original purpose of the Dry Bones skeletal survey was to evaluate temporal bones from the region to see if ramifications of middle ear disease persisted in dry temporal bones, and whether the otosclerotic process is identifiable in a skull after interment. Demonstration of stapes fixation would provide convincing evidence of impaired hearing during life and an indication of the antiquity of this disease.
But before a search for stapes fixation could begin it was necessary to know the survival capabilities of the auditory ossicles in human burials, and whether soil or environmental conditions influenced their preservation. In addition,it was desirable to know whether and how oftenthe stapes footplate remained in the middle ear's oval window. No reference to this subject was in the available literature.
Table 3.6. Auditory Ossicles: North & South Dakota Temporal Bones*
Ossicles Isolated All or
__Age___________Malleus___Incus___Stapes___Stapes-OW**___Multiple***
Premat/Birth 5
B - 10 yr 9 5 2 31 9
11 - 20 yr 2 - 1 4 13
21 - 30 yr 21 15 3 17 31
31 - 40 yr 18 8 3 15 22
41_-__plus_________7________7_________________5_____________5_________
Total 57 35 9 77 80----- 361
* Temporal bones: North Dakota = 243 (149 individuals)
South_Dakota_=_417_(227_individuals)
Total 660 376
** OW= Stapes found lodged in oval window.
*** 83 Temporal bones total, 27 additional stapes in oval window.
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Our research showed that auditory ossicle preservation was variable in skulls from all portions of the region and periods in time (Table 3.6), and their presence and condition were unrelated to the type of burial, conditions surrounding it, or the soil (125,134,142,165,166,301).
Stapes fixation has not been seen in Dakota Territory archaeological material. However, a single instance of unilateral otosclerosis, the only case reported in the literature to date, was discovered by Walter Birkby in the ear of a probable Spaniard who was buried at the Presidio in early 18th century Tucson (47).
Markup by Larry Zimmerman, 1/4/98
