Residua of trauma, infections, tumors, and degenerative disease leave dramatic evidence in human skeletons, but changes produced by metabolic processes are much more subtle. When the Dry Bones project began in the early 1960s, interest in metabolic and nutritional problems in ancient human remnants was in its infancy. In 1971, a bibliography of human paleopathology by Armelagos and co-workers (22) contained 1,907 references dating from 1805 through 1971. Eighteen articles discussed metabolic diseases, nutrition was the topic in eight. In 20 others metabolic disease was referred to indirectly and 15 mentioned nutrition (total- 61, 3.2%). Thirty six of these articles were written after 1960. During the following decade, and subsequently, this facet of paleopathology was explored extensively and many reports are in the literature(16,17,21,22,28,46,56,101,102,103,104,110,116,118,119,191,205,215,302,336).
Because there was little interest in them, and very few criteria upon which we could focus attention, during the early stages of the Dry Bones project no special effort was made to locate evidence of problems of nutritional and metabolic origin. As the result, a considerable number of skeletons we examined were not evaluatedwith these problems in mind.
The first good evidence of the nutritional status of Upper Missouri Basin aborigines evolved from demographic profiles provided by cultural data and osteometric evaluation of salvage archaeology skeletons (33,34,44,112,174,244,245,250,251,331,333). The best opportunity to look for abnormalities accruing from metabolic problems came in 1978, when the Crow Creek mass burial was exposed and the skeletons became available for study, albeit briefly (361). The majority of our experience in this facet of paleopathology came from these skeletons.
DEFINITION OF TERMS
Metabolism is the sum of the physical and chemical processes through which protoplasm is produced, maintained, and eliminated (anabolism), and the process by which energy is made available for function (catabolism).
Nutrition is the mechanism by which food material is taken in and utilized.
The metabolic processes, of which nutrition is an integral part, are interrelating and interreacting complex chemical activities, the majority involving bone in some way. Through these processes chemical substances are taken into cells, utilized or assimilated, and eliminated (36-23;220).
Metabolic disorders are of three types:
Some metabolic disturbances have more than one effect, depending upon whether a substance is in over supply, or deficient, e.g., soil fluorine content. When fluorine is deficient, dental caries are frequent; when it exceeds certain limits, dental mottling occurs.
From about the seventh week after conception and throughout life bone is a dynamic living tissue, constantly changing in response to the stimulus of growth and various stresses. Many factors influence it, e.g., age, sex, nutrition, vascularity, endocrine function, heredity, and physical and emotional illness. It provides support for the individual, allows mobility, and acts as a storehouse for certain chemicals and blood forming elements.
Normally bone remodeling parallels growth and development and the problems of living (physical exertion). Closure of epiphyses at about the 18th birthday signals onset of adulthood. Prior to final epiphyseal closure, distal metaphyses of bones are vulnerable to trauma, infections, and growth disorders, and are potential sites for malignancies. Structural changes accompanying physiological or pathological stresses may persist. Those which persist provide indicators of events during the life of the individual represented by a skeleton.
Four skeletal manifestations of metabolic diseases are:
A combination of effects is possible, e.g., osteoarthropathy (246-288,298;302- 253;346-7,41,55).
Physiological and pathological disturbances affect the skeleton in limited ways, but some metabolic problems have similar effects, confusing the issue as to which process was active. Structural alterations in skeletons attributable to metabolic disorders have included:
THE PRESENT
Diabetes
In North American Indians today diabetes is the commonest metabolic problem. Depending
upon age group and tribal affiliation, it is 2-4 times as frequent in Indians and Alaska
Natives as the U.S. All Races rate (172-18). Diabetes is thought to have been infrequent
in Indians 50 years ago, but during the past 20 years it has increased markedly (? better
recognition), especially in certain tribes. As in other Mongoloid people Indian diabetes
is almost totally non insulin-dependent and ketosis resistant (294-198).
Neel postulated Indian diabetes as being a "thrifty" genotype; an adaptation to a feast or famine economy. He hypothesized that people existing in a milieu of alternating plentiful nutrition and food scarcity, developed the ability to store excess food-stuff as adipose tissue during times of plenty, and to use the stored energy economically and without side effect during times of deprivation (233). This view is not universally accepted today.
In 1981, "Endocrine, Nutritional & Metabolic ranked 9-10th as reason for admission to Aberdeen Area Indian Hospitals, and 3-7th for ambulatory patient care. In 81.1% of hospitals admissions for metabolic disorders the diagnosis was diabetes (uncomplicated- 35.3%, complicated-45.8%), followed by fluid, electrolyte, acid-basebalance problems (8.2%), other diseases of endocrine glands and other metabolic disorders (4.1% each), and thyroid gland disorders (1.2%) (1,292). During the interval 1975-1977, 52/1826 (2.8%; 32.3/100,000) Indian deaths in this area were attributed to diabetes mellitus (292).
Complications accompanying Native American diabetes nationally and in this region include eye changes (retinopathy), renal disease, and occlusive vascular disease involving primarily the heart and lower extremities. Diabetes affects the legs' blood supply, often terminating in gangrene. Amputation of gangrenous feet and legs is required quite frequently in diabetic Indians today (294-203).
Obesity.
Paralleling the accelerating number of diabetics has been a concomitant marked increase in
the amount of obesity. Observers in the past reported that the Indians of yesteryear were
usually lean, testifying that obesity is a recent phenominon. Generally, tribes having the
highest rate of diabetes today also have the most obesity. Obesity and diabetes show
definite familial patterns (167-156,191;294-200).
Osteoporosis.
Today, the Indian population is aging, and senile (primary) osteoporosis (Ch. 6), a
degenerative skeletal disease fundamentally of metabolic origin, especially prevalent in
females, is becomming increasingly common throughout the United States and this region. As
longevity in regional Indians increases it may be anticipated there will be corresponding
increase in the amount of primary osteoporosis. Osteoporosis secondary to specific
metabolic, nutritional, and other problems occurs in the general population and in Indians
today, but is less frequent than in the past.
Goitre.
Goitre is not frequent at Indian Reservations clinics in this region today. A report
dating around 1900 indicated goitre ranged from 1.1-61.4 per thousand Upper Missouri River
Basin Indians, but cretinism was rare (167-199). Although goitre, per se, has no
characteristic effect on the skeleton, bone changes may accompany cretinism. The
significant decrease in frequency of thyroid disease compared to historical references is
attributable to iodized salt.
THE PAST
Mild disorders of chemical imbalance could be compatible with survival in a primitive
society, but it is unlikely that those affected by severe disturbances would live long. In
addition, skeletal evidence of metabolic disease takes some time to develop. Therefore, it
might be expected that residua of serious metabolic disease would be unusual in the Upper
Missouri Basin. This has been our experience. This is despite the fact consanguinity and
incest, both catalysts for inborn abnormalities, were reported as part of the Arikara
culture (Ch. 8) (90).
Non-lethal metabolic disturbances might have occurred in certain portions of this area. In several places soil fluorine far exceeds the threshold for tooth mottling, yet mottling has not been apparent in aboriginal skulls. Throughout western Dakota Territory pockets exist where soil selenium is high, or very low. This is of interest doubly because selenium has been implicated as influential upon teratogenesis and carcinogenesis. Nothing interpretable as selenium poisoning has been apparent. No abnormality suggesting the effect of rickets has appeared in this region's skeletons.
The well being of a population is contingent upon food-stuff, which in turn depends upon the availability of essential nutrients. The nutrition, diet, and food-stuff consumed by contemporary Dakota Territory Native Americans were investigated by Wuerffel (357) and Bass and Wakefield (32). Food of reservation Indians is similar to the general population, but in counties containing Indian reservations diets were poorer. Consumption patterns reflected the arrival of checks and distribution of government commodities, with little evidence of budgeting. There was no typical day's menu; food consumed lacked variety. Occasionally the diet was supplimented with locally available traditional food-stuff that included wojapi‚ (fruit pudding), fry bread‚ (biscuit dough fried in deep fat), and wasna‚ (mixed dry berries, powdered dried meat, fat, and sugar). Although available, wild fruits and turnips were no longer used extensively. In the traditional way some families ate liver and kidney raw; frying, and the traditional method of boiling, were used equally in food preparation (32).
Recipes for preparing indigenous food-stuff by Dakota Territory Sioux Indians in early times were compiled by Schoettger. Traditional wojapi recipes utilized wild cherry, gooseberry, roseberry, strawberry, Indian apple, Indian corn, and plum. Wasna was made from corn and beef. Many ingredients made soup (Indian corn, hoof, ribs and milkweed, tree mushrooms, wild artichokes, paunch, and meat from many animals, birds, fish, reptiles, and vegetables). Cherry bark, Juneberry, wild rose, plum leaf, and peppermint were used for tea. Corn, pumpkin, squash, wild turnips, and fruits and berries were dried. Boiled and/or roast comestibles included buffalo, prairie dog, skunk, roast and braided guts, and turtle eggs. Indian sausage was prepared from beef gut stuffed with meat and suet (289).
Parmalee evaluated animal and avian bones from cache pits, earth lodge remnants, and village refuse disposal sites in South Dakota as indicators of aboriginal dietary constituents and nutrition (257,258). He found pathologies mostly of traumatic origin in avian bones from Arikara sites in South Dakota commensurate with injuries sustained during pursuit by natives (256).
Studies of nutrition, present and past, offer insight into utilization of indiginous food-stuff and changes in dietary patterns over many generations in this region. During the time span portrayed in skeletons evaluated during the Dry Bones survey, survival were based upon hunting and gathering, agrarian practices, or a combination (Ch. 1). The survival of planted crops, fruits and berries, and the availability of herds of grazing animals, were interrelated with climatic conditions.
Kerr evaluated meterological implications of weather, climate, and solar radiation upon the atmosphere over extended intervals in time. A correlation was found between solar activity and drought in the western United States: - drought in the American West since 1600, as recorded in the thickness of tree rings, was related to the 22-year solar cycle of changing magnetic polarity (twice the 11-year cycle of sunspot number) (183). Using a chart showing changing ocean levels, Hurt analyzed cultural and climatic changes in the northern Great Plains during the archaic stage (10,000 to 2,000 years B.P.). Lack of applicable geological data relating to the northern plains climatic cycles forced this approach. He assumed that low temperatures and moist conditions in the northern plains accompanied low sea levels, leading to enlarged herds of grazing animals and conditions favorable to increased human population. During high sea levels, the converse could be expected. Archeological findings from the northern plains were presented to support this contention (170).
In addition, Hurt described seasonal economic and varying settlement patterns in the Arikara culture during the Late Prehistoric and Early Contact periods. During these intervals the Arikara lived in villages along the Missouri River and adhered to relatively stable seasonal activity patterns that included:
Earth lodges provided shelter during planting and harvest seasons, and during the Winter. Tipis sheltered hunters, while those unable to participate in hunting activities remained in the villages (171). Lehmer also investigated the climate and cultural history in the Middle Missouri Valley(194). As might be expected, periods of inclement weather or other factors, by interference with the food supply, stimulated inter-tribal negotiation, or warfare for the available food and food procurement resources in the region. Warfare with the Dakota invading Arikara country from the northeast, and the ravages of communicable diseases accompanying European invasion decimated the Arikara and Mandan populations, leading to concentration of these tribes in permanant earthlodge villages. The changed existence pattern altered the Arikara life style during the 19th century, increasing their role in agriculture and commerce, and decreasing their reliance upon the hunting economy (171,238,245). The different economic and social structure of the Arikara culture was accompanied by nutritional stress that undoubtedly contributed to the devastating effect the communicable diseases had upon their people(238).
Historical references indicate that metabolic problems were prevalent in the ancient Americas, both in the Indians and the European invaders. Ashburn reported that clear accounts exist of scurvy in the summertime (24). Nutritional stress, especially in the winter, was reported in the Missouri Basin (25-46,55,183,238;77-35,310;171;217-8,118,136,152,209). Non-availability of food-stuff has been hypothesized as an importantfactor in the mid-14th century Crow Creek massacre (361, 362).
Figure 5.1. 39WW2 Larson cemetery. Arikara child 2-3 yr.
HISTIOCYTOSIS X‚ (eosinophilic granuloma, Letterer Siwe disease, Hand-Schuller-Christian disease).
Circumscribed, round and irregular osteolytic islands with slight, spotty osteosclerosis peripherally, apparently original in the medullary space, involve all layers of the frontal, parietal, and occipital portions of a child's skull (Fig. 5.1). Accentuated vascular markings on the parietal bones' medial surface are secondary to meningovascular engorgement in response to the pathological process. The radiograph shows skull lesions but none in long bones. Although a metastatic neoplasm must be suspected, the radiographic appearance was interpreted as more typical of Histiocytosis X (141).
Osseous changes are caused by clusters of fat containing histiocyte cells in marrow spaces, producing focal expanding osteolytic defects. The mandible, clavicle, ribs, pelvis, and vertebrae may also be involved. Histiocytosis X is a generalized non-malignant disease, originally thought to be three different diseases. With treatment the prognosis for survival is good. This is the only such abnormality from this region (141;364-68,131). Two skeletons with similar findings have been reported (225-120;302-355).
DIABETES MELLITUS
Diabetes has no direct effect on the skeleton. Indirectly through occlusive peripheral vascular disease leading to gangrene, lower extremity disease can end in amputation. In Figure 2.16, an isolated knee from North Dakota with no provenience, was amputated through the upper calf. This could have been of traumatic origin (physical or thermal) or secondary to infection or arteriosclerosis, but a diabetic complication is possible. Survival with a gangrenous, infected lower extremity would have been problematical, but apparently occurred in this instance.
Historical information pertaining to diabetes generally was assembled by Brothwell and Sandison (62- 235,243,552), and to American Indians by Vogel (335-151,198,296). No anatomical specimens are reported in available paleopathology literature.
NON-SPECIFIC INDICATORS of Altered Metabolism
Skeletal modifications attributable to metabolic disturbances were in the cortex, medullary space, or both. Cortical alterations included changes due to periostial affectation (orbital and cranial cribra, subperiostial hematoma, periostial elevation), surface changes near growth plates (epiphyses) of long bone ends (metaphyses), and loss of mass due to defective bone production or excessive breakdown. Marrow space changes were architectural modifications (transverse lines, altered trabeculation, cortical thinning due to disturbed intramedullary physiology). Altered bone density was an expression of either corticalor marrow space abnormality, making interpretation difficult.
ORBITAL and CRANIAL CRIBRA
Orbital cribra were in skulls of a young woman and a child (Fig. 5.2). Similar lesions
were in the child's occipital cortex (5.2C). The young adult's lesions appear old and
quiescent, but those in the child's skull are active. In 28/392 identifiable Crow Creek
skulls, 18 isolated orbital cribra and 4 had cribra and other lesions (Table 5.1; Fig.
5.2). Orbital and cranial cribra have been identified in skulls from elsewhere
occasionally (Table 5.2).
Figure 5.2. 39BF11 Crow Creek. Proto-Arikara. A. Female 18-22 yr. B,C. Child 6-8 yr.
Table 5.1. Orbital Cribra and Porotic Hyperostosis, Crow Creek Skulls (N= 392)
Adult Sub-adult Child
_____________________Old_____Active______Old_______Active_______Active________Total___%___
Cribra orbitalia 6(2) -- -- 2(1)* 10 18 4.8
Porotic hyperostosis
*
Frontal 4(2)* 1(1)** -- -- -- 5 1.3
(1)**
Frontal-parietal 16(2)* -- -- -- -- 16 4.1
Parietal 23(2)*** -- 1 -- -- 24 6.1
Occipital 3 1(1)** 1(1)**** 3 4(2)** 12 3.1
Temporal (N=963) 6 1(1)**** -- -- 3(2)** 10 1.0
(1)****
Maxilla (N=129) 1 1(1)**** -- -- -- 2 1.5
Mandible (N=131) -- 1(1)**** -- -- -- 1 0.76
* with supraorbital involvement.
** associated with cribra orbitalia.
*** associated with occipital involvement.
**** associated with recent subperiostial hemorrhage.
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Table 5.2. Porotic Hyperostosis & Cribra
Site Porotic Orbital
Skeletons__Culture__Hyperostosis__Cribra__
No. % No. %
Swan Creek
39WW7 Arik 11 13.4 1 1.2
N= 82
Mobridge
39WW1 Arik 4 7.2 2 3.6
N= 55
Four Bears
39DW2 Arik 2 4.8 1 2.4
N= 41
DeSpeigler
39RO2 Woodland 2 4.0 - -
N= 50(est)
Ufford
39CL2 Woodland - - - -
N= 40
Double Ditch*
32BL18 Mandan? - - - -
N= 24(est)
ND Hist. Soc.N = 151** Several - - - -
Over Coll.#
N= 228 Several 16 7.0 3 1.3
Misc. Coll.
& Spec. Several 3 1.2 - -
N= 241
__________________________________________
Total 912 38 7
* Bones fragmented.
** Study focused orimarily on ear disease.
# Periostial elevations 2 skeletons.
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LOCALIZED PERIOSTITIS (Old and Recent Subperiostostial Hemorrhage)
Multiple long bones, have changes suggesting subperiostial hematomas in various stages of
organization. In 5.3B the process appears active at death; those in 5.3A and 5.3C are
partially organized. In 5.3D, rounded, localized islands of old osteoanagenesis (arrows)
suggest multiple past subperiostial hematomas. In addition Bone 5.3D appears to have been
affected by osteomyelitis.
An unusual finding in Crow Creek skeletons was the inordinately large number of bones with focal cortical changes that appeared to be old and organizing subperiostal hematomas (Table 5.3). In addition, many were on surfaces of bones not usually exposed to direct trauma (Fig. 5.3A). Probable subperiostial hematomas were on 198 bones; 43 old and smooth (multiple in 5); 47 old, and active or healing (5 multiple); and 108 active or healing. Bones involved by hematomas most often, compared to the total number of bones counted were: tibia 86/531 (16%); fibula 29/299 (10%); humerus 24/418 (5.7%); and femur 31/734 (4.2%).
Osseous defects interpreted as residua of recent subperiostial hematomas were on 60/531 (11%) tibias and 24/299 (8%) fibulas. If the 531/972 tibias and 299/972 fibulas found/expected in the 486 individuals identified at Crow Creek are used as an index, the evidence strongly suggests that a high proportion of the Crow Creek population was affected by a problem promoting formation of subperiostial hematomas at death.
Figure 5.3. 39BF11 Crow Creek. A- femur, C- tibia, D- tibia, all adult. B- tibia, subadult.
Table 5.3. Crow Creek Bones, Localized Periostitis Suggesting Subperiostial Hemorrhage
Adult Sub-adult Child
Bones Both old
Bone_______Counted____Old_______Recent__and_recent___Old__Recent___Recent___Total_____%____
Tibia N=531 26 10 26 -- 21(19)* 3(3) 86(22)* 16.2
multiple= 4 multiple= 5
Fibula N=299 5 9 9 -- 6(6)* -- 29(6)* 10.0
multiple= 1
Humerus N=413 3 3 5 -- 12(9)* 1 24(9)* 5.8
Femur N=734 1 10 1 1 16(14)* 2(2)* 31(16)* 4.2
Ulna N=244 4 1 3 -- 1 1 10 4.1
Clavicle N=233 3 1 -- -- 2(2)* -- 6(2)* 2.6
Radius N=206 -- 1 3 -- -- -- 4 2.0
Scapula N=521 -- 1 -- -- 1 -- 2 0.38
Temporal N=963 -- 1(1)** -- -- -- 1(1)* 2(2)* 0.2
Occipital N=--- -- -- -- -- 1(1)* -- 1(1)*
Maxilla N=129 -- 2(1)** -- -- -- -- 2(1)** 1.5
Mandible____N=131_______--__________1(1)**_--_________--___--_______--_______1(1)**___0.76
Totals 42 40 47 1 60 8 198
* Concomitant accentuated vascular markings at ends.
** Concomitant old porotic hyperostosis
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Figure 5.4. 39BF11 Crow Creek. Proto-Arikara male adult.
Calcified subperiostial hematomas on long bones exposed to trauma, particularly the tibia's anterior surface from 'barking the shins,' have been found quite often (Fig. 2.15). Old subperiostial hematomas appeared as smooth, rounded, osseous islands protruding from the bone's surface (Fig.5.3D). Those under going organization have been distinguishable from older lesions by their appearance, and by the density of the new bone (Figs. 2.15, 5.3A, B, C).
The lateral surface of a temporal bone has cortical changes indicating an active inflammatory process (Fig. 5.4). Although infectious origin must be considered, it does not present this appearance, and resembles nothing that has been seen previously during our work. We question whether this represents hemorrhage into softtissue overlying the temporal bone.
PERIOSTIAL ELEVATION
Three childrens' bones present the appearance of a bone within a bone (Fig. 5.5). In 5.5 A&B alterations are localized eccentrically in a 4-6 yr. old's proximal femur, where the trabecular pattern has an "on end" configuration. Changes in a fragmented tibia (upper) and femur (5.5C) involve the entire bone shafts. In all specimens the effect is that of a medullary cavity surrounded by two cortices, separated by a layer of trabecular bone. Only fragmentary other skeletal components were available, so search for concomitant abnormal bones was not possible.
Such changes begin with edema (swelling) that lifts the periostium off the bone cortex, then deposition of osteoid material beneath it, followed by mineralization. Osteoblastic activity spreads so the ends of long bones become sheathed in a cuff of new bone. Bones affected by this process are weakened and subject to pathological fracture. This type change resembles somewhat skull alteration as expressions of porotic hyperostosis or cribra orbitalia, and sub-adult long bone end changes in individuals with iron deficiency anemia. Mensforth and co-workers emphasized the importance of this abnormality as a criterion of metabolic bone disease (215).
Periostial elevations in tubular bones accompany metabolic disturbances (215-8), sickle cell anemia (275), and chronic heart and lung diseases (259-298). Clinically, clubbed digits, arthritis, and periosteal bone formation are part of hypertropic osteoarthropathy. It can be hereditary, secondary to cardiopulmonary diseases, accompany chronic diarrhea, and mimic syphilis or subperiostial hemorrhages accompanying trauma or scurvy (39-201,2263).
Although not frequent, periostial elevations have been found in bones from several childrens' skeletons, but were not observed in Crow Creek bones.
Table 5.4. Accentuated Vascular Markings
Crow Creek Child & Sub-adult
Distal Metaphyses
Bone_______Subdult________Child___Total
Tibia 31 (19*) 9 (3*) 40
Femur 26 (14*) 10 (2*) 36
Humerus 19 (9*) 3 22
Fibula 7 (6*) -- 7
Clavicle 2 (2*) -- 2
* Concomitant recent subperiostial
hemorrhage.
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Figure 5.6 shows the growth zone of a sub-adult femur, and its radiograph. In the radiograph three faint transverse lines are near the epiphysis. The cortex is thin but the medullary pattern is not abnormal.
Figure 5.6. 39BF11 Crow Creek. Proto-Arikara sub-adult.
Fine lines that represent minute vascular channels running in the femur's long axis toward the epiphysis are more prominent close to the growth plate. Because metaphyses, especially in the appendicular skeleton, grow rapidly during childhood and adolescence, increased vascularity is expected. The vascular pattern here is slightly accentuated and more irregular than in most regional sub-adult skeletons.
In many Crow Creek children's and sub-adult long bones the vascular response near the growth plates was more evident than has been apparent in other regional skeletons (Figs. 5.6, 5.7). Furthermore, the vascular changes showed considerable variability in bones from individuals who probably were about the same age at death. In sub-adult skeletons alterations were most prominent on proximal tibiae (40/?), proximal and distal femora (36/?), and proximal humerae (22/?), Table 5.4.
A distal femur (Fig. 5.7, Bone 1), and two proximal tibii show different types of cortical modification near the epiphyses, and on the bone shaft (5.7, Bone 3, arrows). Distal metaphyseal alterations in Bone 1 (arrows) are prominent, those in Bone 3 are minimal. Several different appearing periostial reactions are etched into Bone 3's surface; two mid-shaft lesions represent organizing subperiostial hematomas. All cortical modifications appear active at death.
The sub-adult distal femoral metaphysis in Figure 5.8 displays growth disturbance we interpret to represent deficiencies in osteoid production and calcium deposition. This has produced a honeycomb effect proximal to the metaphyseal-epiphyseal junction. The process appears active.
Figure 5.7. 39BF1 Crow Creek. Proto-Arikara. Subadult bones.
Figure 5.8. 39BF11 Crow Creek. Proto-Arikara.
Figure 5.9. 39BF11 Crow Creek. Proto-Arikara.
Multiple humeral radiographs, all adults except Bone C. Cortices in 5.9B-C are thin and their medial surfaces are irregular. Surface alterations in 5.9A (arrow) suggest old reaction. In 5.9A,B,C, distal medullary patterns are indistinct, and 5.9C has a ground glass appearance. The distal medullary pattern in 5.9D&E is coarse, and in 5.9E an accentuated "V" or "/" pattern extends cephalad to the bone's midportion.
In Figure 5.10A,B, the cortices are thin. All radiographs except 5.10C have transverse lines. Trabecular patterns in 5.10A,B,E are indistinct.
Similar to other Crow Creek radiographs, in the sub-adult distal femur (5.10F), there are multiple dense lines and disturbed medullary trabecular pattern near the epiphyseal plate. These radiographic changes indicate recent disturbance of bone production in the epiphyseal area of a growing individual.
Reduced long bone cortical thickness was present in 221/411 (54%) humeri and 258/657 (39.3%) femora (Figs. 5.9B&C, 5.10A,B,D.E, Table 5.5). These findings are those of osteoporosis secondary to metabolic disturbance.
Secondary osteoporosis was a prominent finding in skeletons of a child from Crow Creek (Fig.7.25) and a teen-aged male from the Rygh site (39CA4) (Fig. 7.26), both of which had chronic debilitating hip disease. In 7.25, congenital hip dislocation or Perthes disease caused degeneration of the femoral head and acetabulum. Thin cortices and decreased medullary trabeculae were secondary to disuse. Changes in 7.26 are attributed to long term disuse and probably muscle spasm accompanying a painful congenital hip dislocation, and degeneration of the hip joint. Growth disparity between bones of the lower extremities indicated a process beginning early in life. The combined extensive secondary osteoporosis, anatomic malformation, and developmental delay in 7.25 and 7.26, portray vividly the effect of metabolic change upon bones involved in long term disability during the growth period.
Decreased bone density was also an accompaniment of chronic debilitating infectious diseases. Skeletons of individuals affected by tuberculosis were often very osteoporotic (Fig. 3.8).
TRANSVERSE LINES
Woodland adult. Fragments C,D (proximal) and E (distal) tibia; F distal fibula. In 5.11A, a single transverse line is 12.5 cm from the tibia's distal end. The tibia's missing distal articular portion and medullary space impregnated with soil indicate para-mortem foot amputation and burial with the marrow space exposed (Ch. 1). In 5.11B, multiple lines extend from just proximal to the area of epiphyseal closure for 7.5 cm.
Figures 5.11 C-F, show transverse lines in sections of broken Middle Plains Woodland long bones (distal tibia and fibula). Multiple lines suggest repetitious disturbance of growth. Such findings help establish the antiquity of metabolic and nutritional stress in this region (800 A.D.).
Figure 5.13. 39BF11 Crow Creek. Proto-Arikara male adult.
Transverse lines were quite common in skeletons from all eras. In Crow Creek long bones they presented as single or multiple lines, and as similar strategically located lines in bones from individuals who were about the same age.
Steve Symes (Anthropology Department, University of Tennessee, Knoxville) analyzed radiographs of 122 complete Crow Creek tibiae, 64 male and 58 female. About 75% of them had at least one line, averaging 1.34 lines per element, the largest number being ten. In total 163 lines were in 92 tibii. When aged, each line fell into the age range 0.5 to 18 years. The most common bone ages for transverse lines were the neo-natal interval and early adolescence. The lines were not sex related (312). In radiographs of a few broken tibii the number of transverse lines exceeded the number Symes reported, the greatest number in one bone being fourteen.
An unusual form of osseous band that has not been emphasized previously, but which probably is a transverse line variant (Stanley Garn, Centerfor Human Growth and Development, University of Michigan, Personal Communication, 1980), was in radiographs of Crow Creek humeri (Figs. 5.9,5.14). It presented as dense, inverted "V" or"/" bands in medullary spaces, beginning just cephalad to the distal articular surfaces, often extending to the humeral mid-shaft (144). Of 418 Crow Creek humeri counted, radiographs were available for 398. In these, 358 (90%) had medullary changes of this type. In many humeri these bands were accompanied by altered medullary trabeculations (Fig. 5.14C).
SKULL DIPLOE ALTERATIONS
Osseous changes in frontal and parietal bones (Fig. 5.12A) indicate intramedullary changes deforming them. Note scalping cut marks right frontal area. 5.12B. Cross lighted view of frontal-parietal junction enhances deformity of the bone's outer cortex. A small osteoma near the left edge is an incidental finding. 5.12C. Parietal bone fragments have wide medullary spaces, deformed sagittal suture, and outer cortex porosity. 5.12D. The parietal bone cut surface shows wide medullary space and thin cortices.
A lateral skull radiograph shows generalized parietal thickening (opposed arrows-white-outer, black- inner), thin cortices, and faint hair on end changes (superior arrow) (5.13).
Table 5.5. Altered Radiographic Patterns Crow Creek Humeri and Femora
Humeri____(N=__418)* Femora____(N=__669)*
_________________________Number_________%_________Number_________%_____
Distal trabeculae 358/398 90.0 122/521 23.4
Cortex 221/411 53.7 258/657 39.2
Medullary space 379/418 90.6 353/664 53.2
* Disparity between bones counted and radiograms is specimens
for which definitive analysis was impossible.
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Figure 5.14. 39BF11 Crow Creek. Proto-Arikara.
Multiple adult distal humeral radiographs. Another skull radiograph had faint hair on end configuration, but only a few films were taken to show lateral projections of the skull, so further investigation was not possible.
Widening of the skull's diploe accompanied by thinning of the outer and inner tables, and increased porosity of the calvarium's surface provide evidence of on going intramedullary disease (porotic hyperostosis). The specimen in Figure 5.12C was an isolated fragment and could not be related to the remainder of a skull or skeleton.
In mild form porotic hyperostosis has been observed in other regional skulls, but no specimens have shown the amount and severity of osseous changes found in the massacre skeletons.
LONG BONE INTERNAL MODIFICATION
Marrow space alterations included coarsening of the internal architecture, distortion of medullary space trabecular patterns, and widening of medullary spaces with thinning of cortical bone (Figs. 5.9, 5.10, 5.14, Table 5.5).
Medullary trabecular patterns are coarse, especially in 5.14C. Humeri all have dense "V" or"/" shaped lines.
Table 5.6. Crow Creek Bone, Analysis For Lead Content
Lab. C.C. Excavation Micrograms lead
I.D.No._____grid_chart_No.____Bone_____per_gm._bone_ash____Comment____________
Box 120 8 C NE Tibia 0.94 Adult-sabre shin
bag 13 USD
Box 60 6 B NE Humerus 3.02 Osteoma bone USD
bag 17 (2)
Box 151 5 A NE Tibia 2.73 Fibrous dysplasia,
bag 2 bone USD (1)
From: Aufderheide, A.C., 1982.
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Changes in Crow Creek long bone marrow spaces, especially noticeable in distal humeri and femora, consisted of coarse striation and very disturbed marrow space trabecular patterns that varied from localized patches or a honeycomb pattern to complete architecture obliteration (Table 5.5). In some long bone radiographs medullary trabeculae were so altered that they presented a ground-glass appearance (Fig. 5.9C, 5.10A,B,E).
Some soil elements e.g., arsenic, bismuth, lead, mercury, and selenium have the potential of profound toxic effect upon humans and animals. Certain portions of South Dakota are known to have high soil selenium content, but the vicinity of the Crow Creek village was not one. About the only heavy metal that might have affected people living in the Dakota Territory in the past, was lead. Lead deposits occur in the Black Hills of South Dakota, but are not known near the Crow Creek site. Unless there was commerce between the Black Hills and the Missouri River Basin during the 14th century, it is unlikely the Crow Creek villagers had sufficient lead exposure for poisoning. However, there were dense lines at the ends of sub-adult long bones (Fig. 5.10F), and medullary trabecular changes suggesting altered erythropoesis, for which heavy metal poisoning could be the cause. It was desirable to investigate this possibility.
Today, lead poisoning is acute or chronic. Acute intoxication occurs where lead is used in industry and commerce. Chronic poisoning (plumbism), an insidious disease, occurs if food or water are contaminated, or if food is processed or stored in unglazed pottery containing lead (46,28).
Plumbism affects: 1. erythrocytes primarily marrow spaces secondarily, causing anemia; 2. smooth muscle, especially in the intestinal tract, causing colic; 3. the brain and certain nerves causing nerve degeneration and impaired function, primarily in wrists and legs, and possibly convulsions; and 4. the kidneys interfering with urine output (224;317-496). Ingested lead is deposited in bones. In adults no radiographic alterations appear, but during growth lead is deposited as dense lines near long bone epiphyses and along flat bone margins. Lead line width varies with the quantity and duration of ingestion (259-245).
To eliminate plumbism as a factor contributing to the 14th century catastrophe at Crow Creek, using atomic adsorption spectrometry (356) Arthur Aufderheide (Department of LaboratoryMedicine, University of Minnesota at Duluth) analyzed three representative bone specimens for lead content (Table 5.6). In a personal communication (1982) he concluded:
Since for practical purposes values much below 2.0 micrograms of lead per gram bone ash are not very reproducable we consider the values to demonstrate either no or only trace quantities of lead. indicating that plumbism was not a factor in the massacre.
THE PRESENT
Metabolic abnormalities have changed significantly in the Upper Missouri River Basin
during the past millennium. Nutritional scarcity and sequellae thereof were most frequent
in the past, but now diabetes and obesity (? over-nutrition) are the largest metabolic
problems confronting the health care team. Present evidence indicates that diabetes and
its sequellae, and obesity, are increasing in Native Americans throughout North America as
well as in this region. Because diabetes has no characteristic osseous changes, and
historical references have no indication of its prevalence in this region, there is no way
to determine its antiquity in the Missouri River Basin(167-182).
Goitre now is infrequent. Historically, goitre was common in Indian tribes living in this region, but it does not affect the skeleton such that its presence during life is identifiable. Despite the reported prevalence of goitre, cretanism, a problem that has skeletal implications, was reported unusual.
Several localities in the Dakota Territory have high water fluorine levels and mottling of teeth is common today, but no mottling was detected in aboriginal skulls. This is best explained by sources of water supply. Aborigines drank ground water. The water supply for communities with high fluorine levels now comes from wells that tap into aquafers.
As part of the search for otosclerosis in antiquity (Ch. 3, Epilogue), an attempt was made to analyze the fluorine content in water sources used in the 18th and 19th century South Dakota Indian villages. Unfortunately, the water sources had dried up, or were lost in the Missouri River Reservoirs.
Lead poisoning, an insidious disease today, was considered as a factor contributing to apparent easy conquest of the Crow Creek villagers. Bone fragments had only traces of lead, insufficient to have affected the people.
THE PAST
Histiocytosis X, the only specific metabolic disease identified, appeared in a young child's skull. The major problem encountered with this specimen was differentiation from metastatic cancer implants.
ABNORMAL METABOLISM, Non-specific Manifestations
Transverse lines" were in many regional skeletons. We accepted them as general indicators of stress during bone growth, and not pathognomonic of specific diseases. These lines, single and multiple, were especially prevalent in bones from the Crow Creek massacre, lending credence to speculation the catastrophe had its origin in prolonged unfavorable climatic conditions, drought, famine, and inter-village warfare.
An unsuccessful attempt was made to correlate transverse lines in bones with accentuated vascular markings on the metaphyseal surface, on the premise that prominent transverse lines close to epiphysis and accentuated surface vascular markings both indicate something interfered with the growth zone near death. This could have been defective osteoid production as occurs with scurvy (225-26;302-253), defective calcium deposition, or protein deficiency retarding the bone remodeling process. Periostial elevations" were found in skeletons from this region, but not often. Their presence in even a few specimens indicates diseases causing them were prevalent in regional aborigines.
Localized periostitis on many Crow Creek bones suggested sub-periostial hematomas and indicated a factor promoting hemorrhage. Furthermore, the presence of old and multiple calcified hematomas in 10 specimens indicated that some villagers had sustained and survived previous hemorrhagic episodes. The finding of focal active and organizing periostial lesions, along with the other bony alterations, provides substantial evidence that the cause had existed periodically for some time prior to the massacre, and probably was active at the time of the catastrophe.
Surface alterations near growth plates" have been noted frequently in the ends of regional childrens' and sub-adult long bones. They represent the vascular response to growth. There was considerable individual variability in these markings. However, in many immature Crow Creek skeletons unusual alterations indicated that some process interfered with bone growth immediately ante-mortem. Very little was found in the literature to explain these findings.
In a non-illustrated presentation, Morse described his findings in over 400 skeletons from the Klunk Site, more than 20% of which were under age two years. The high proportion of very young individuals resembles demographic findings from several South Dakota cemetery populations. In Morse's skeletons there was osteoporosis of variable degree, growth arrest lines, obliteration or partial loss of medullary spaces, and "swelling of bone ends." He attributed these changes to non-specified nutritional problems (225-29). His description of changes he saw suggests they were similar to distal metaphyseal alterations other modifications in the bones from Crow Creek.
In the San Diego Hrdlicka Paleopathology Collection three femurs from children 5-9 years of age have distal metaphyseal vascular changes similar to those being discussed. These are attributed to tendon involvement (329-229).
Decreased bone mass, Cortical bone atrophy
Excellent examples of severe osteoporosis secondary to prolonged debilitating congenital
disease were found in 14th and 17th century sub-adult skeletons with hip dislocations.
Similar changes accompanied chronic infection by tuberculosis. Cortical density changes
probably of metabolic origin were found frequently in Crow Creek skeletons.
Marrow space changes
Medullary and cortical changes in Crow Creek skulls and long bones suggest the effect of
intramedullary pathology, and the possibility of other metabolic disease. The multiplicity
of osteological findings defy explanation on the basis of a single metabolic or
nutritional entity.
Definitive analysis has convinced us that metabolic disturbances were key elements in the catastrophe that brought the Crow Creek village to its end. The evidence, old and active, indicates that probably three primary factors were or had been operative. These included: 1. repetitious and active lack of essential nutrients; 2. prolonged deficiency of dietary iron; and 3. previous and active ascorbic acid insufficiency (scurvy).
Periodic metabolic stress
Horizontal intramedullary bands in long bones were of special interest in Crow Creek
skeletons because it was hypothesized that the catastrophe's most likely cause was
prolonged unstable climate and drought in the region, leading to inter-village warfare for
possession of scarce food and food processing resources (Ch.1) (361).
Transverse lines indicate temporary growth disturbance and do not form unless the individual recovers or receives adequate nutrition (111;302-253). A population suffering from chronic malnutrition has fewer transverse lines than one exposed to periodic or seasonal starvation, and good nutrition (302-43).
Anything disrupting homeostasis during the period of growth (debilitating illness or injury, or m etabolic disease), can be instrumental information of transverse (Harris, growth arrest) lines in medullary spaces. They are most visible in long bones, especially distal tibii (111). Transverse lines can persist, or be eliminated through remodeling (111,205,215). In people living here today transverse lines generally, and in humeri particularly, are infrequent in radiographs.
Radiographs of Crow Creek bones demonstrate that a significant number of the villagers had been subjected to stress sufficient to disturb bone growth on one or more occasions. Bands of variable density near epiphyses within sub-adult long bones and disturbed ossification on their surfaces indicated growth disturbances at or near death.
Dietary iron deficiency
The massacre at Crow Creek was postulated as part of the struggle for survival, brought on
by prolonged climatic instability and food scarcity (Ch. 1), so indicators of past and
active nutritional depletion were needed to confirm the hypothesis (361). These people
were hunter-gatherers and farmers (corn, beans, squash). If the supply of animal protein
and iron were severely reduced during a prolonged drought, vegetable protein and iron
could have been the only source available. A correlation has been shown between maize
(Indian corn) as the major dietary staple for protein and iron, and porotic hyperostosis,
an indicator of dietary iron deficiency (103,336).
Medullary trabecular changes and cortical bone atrophy in skulls and long bones as well as skull surface markings, accompany diseases affecting red cell production (erythropoesis). Angel reported that in children and adults the effect of iron deficiency anemia (porotic hyperostosis) usually centers in diploe (16,17), but other nutritional deficiencies such as mild rickets and scurvy, as well as porotic hyperostosis, can affect the skull's outer surface. Changes varying from tiny perforations to sieve-like porosity in the calvarium's outer surface may be due to mild rickets or scurvy (16), or have other causes (17;215-4;246-248;302-213). Similarly, cortical bone defects in superior orbital plates (cribra), usually attributed to anemias, can accompany other abnormalities (215-4;302-243).
Mensforth and co-workers reported that in infants and children skeletal alterations of porotic hyperostosis fit the age-specific distribution of hypochromic microcytic (iron-deficiency) anemia (215).
In a clinical study Aksoy and co-workers showed that medullary and cortical changes similar to those in Crow Creek long bones are part of iron deficiency anemia. Radiographs of twelve individuals with nutritional iron deficiency anemia had alterations typifying erythroid hyperplasia (marrow expansion accompanying insufficient dietary iron). Tubular bone alterations consisted of: 1. coarse trabecular striation at bone ends; 2. osteoporosis; and 3. variable marrow space distortion ranging from patches or a honeycomb pattern to complete medullary architecture obliteration.
Skeletal alterations were most frequent in patients' elbows (11/12), but were present in 5/12 skulls, 5/10 knees, 9/11 hands, 3/11 pelvic bones, 3/10 vertebral bodies, and 3/7 foot bones. The patient with most pronounced skeletal changes had no skull abnormality. Re-examination of one patient after a year's treatment with iron showed no radiographic improvement, suggesting that trabecular pattern alterations induced by iron deficiency persist (5).
Aksoy (Department of Hematology, Capa Internal Clinic of Istanbul Medical School, Personal communication, 1983) provided copies of his patients' radiographs for comparison with those of Crow Creek skeletons. Alterations in distal humeri and femurs were the same in his and our films.
Dietary deficiency in amino acids and minerals fundamental to bone formation and replacement are important factors in osseous changes accompanying iron deficieny anemia (5;102;191;302-231;336). Von Endt and Ortner analyzed amino acids in bone of a prehistoric Southwest Indian child and compared the findings with control specimens. They postulated that protein synthesis was altered in the child, and either proteins needed for early phases of mineralization were not produced in sufficient quantity, or essential cofactor enzymes (dietary ferrous iron) were missing.
Logistical problems precluded amino analysis on Crow Creek bones, but the anatomic and radiographic modifications in materials supplied to us (D.W. Von Endt, Smithsonian Institution, Personal communication, 1983) show changes identical withwhat we found.
Two radiographic alterations in a few Crow Creek skulls, the "hair standing on end" in diploe, and altered paranasal sinus development (pneumatization), have in the past been considered unusual in iron deficiency anemia. They are more characteristic of thalassemia, but are found in other types of anemia (5;228;302-218). Overgrowth of marrow during growth of the maxilla, sphenoid, frontal, and temporal bones, particularly the maxillae and sphenoids, disturbs pneumatization of the sinuses and mastoids, and may completely suppress it (302-220). Cooley's anemia was reported in American Indians, but is not common (228-1;203).
From the gross and radiographic examinations of Crow Creek bones it was not possible to tell whether alterations of iron deficiency anemia and chronic under nutrition were totally of dietary origin. The possibility of intestinal parasitosis, and other factors was considered, but could not be proved. In addition, in adult skeletons it was not possible to correlate cortex and marrow space findings with sex. Ascorbic_acid_depletion (scurvy). Subperiostial hemorrhage appearing as localized periostitis is one of the most common manifestations of infantile and adult scurvy (179). If the victim survives, bone surface hemorrhages may resorb, or be calcified. As well as subperiostial hemorrhages, skeletal changes accompanying scurvy in infants include thin long bone cortices, metaphyseal fractures, changes in wrists, knees, and costochondral junctions, and a ground glass appearance in metaphyses from trabecular resorption and deficient formation. Scorbutic skeletal changes in adults are the same except that epiphyseal changes are not present (364-66).
Scurvy follows prolonged ascorbic acid deprivation and often appears during famine (290a). Those suffering from scurvy, especially infants, are very ill and susceptible to infections (302-213). Epidemics of scurvy occurred in Australian aborigines during drought (31a). Subperiostial hemorrhages in 27% of adult Maya skeletons suggest that scurvy contributed to the fall of that empire (286,287).
Focal, single and multiple outer cortex lesions, signifying localized periostitis, were frequent in Crow Creek bones from people of all ages. Different appearing lesions indicated old, recent, and healing subperiostial hemorrhages. Bones of the lower extremity were affected most often. The finding of calcified hemorrhages implied that during life the person had been affected by but had overcome a disease associated with intra-corporeal bleeding. Physical trauma frequently precipitates subperiostial hemorrhage, especially on the tibia's anterior surface, but many of the lesions were on bones well protected by soft tissue.
The bone pathology interpreted as active and resolving subperiostial hematomas, and surface findings near epiphyses of juvenile long bones and in radiographs, indicate on going disturbance in these bones at the time of death. In growing bones scurvy may be accompanied by defective bone production, and hemorrhage into growth plates and contiguous structures (225-28;259-109). Morse described the pathophysiology in youthful scorbutic individuals as retardation or cessation of bone production while resorption proceeds at the usual rate (225-26). This appears to be what was happening in 14th century sub-adults, in Buffalo County, South Dakota.
Assuming that some alterations in Crow Creek bones represent active scurvy, what might these tell about the sequence of events in the mid-14th century.
Scurvy does not become manifest clinically overnight. The symptoms and findings appear after prolonged complete ascorbic acid deprivation. In a controlled study plasma ascorbic acid levels in volunteers on a diet deficient in Vitamin C fell to zero by the 41st day, but evidence of scurvy, exemplified by abnormal hair and hair follicles, did not appear until after four months. Perifollicular hemorrhages were not evident until after five months. Non-specific subjective symptoms of fatiguability and loss of appetite preceded objective findings (290a).
Historically, Vitamin C deficiency occurred most often during Winter, when sources of the vitamin were not readily available (25-46,55,183, 238;335-3,84,249,326). However, North American aborigines are reported to have had knowledge concerning sources of Vitamin C, and reputedly were able to prevent and treat scurvy (335-3,84, 249;246-272).
Had there been an extended drought in the region, especially if for several years, green vegitation and fresh meat necessary to supply Vitamin C would have been in a marginal state of supply for a long interval. In addition, it is possible that a prolonged state of siege may have confined the villagers, limiting their ability to obtain essential nutrients, and contributing to the nutritional depletion.
By virtue of the fact that Vitamin C deficiency was most likely during the Winter and the skeletons show what appear to be residua of active and healing subperiostial hemorrhages, it is very likely the massacre occurred during the winter, probably in March or early April.
The picture that emerges for the village at its end is one of periodic dietary deficiency in essential nutrients over a prolonged interval, inadequate iron intake of long standing, and previous episodes of scurvy. Starvation, profound malnutrition, active scurvy, and famine were active at death. Their weakened condition undoubtedly contributed to the villagers' fate.
Markup by Larry Zimmerman, 4/21/98
