Improving the use of historical written sources in paleopathology

Exploring the antiquity of rheumatoid arthritis: A case study from medieval Transylvania

OBJECTIVE

To evaluate erosive pathological lesions on a skeleton from medieval Transylvania.

MATERIALS

A skeleton from a Székely archaeological site in Transylvania was examined and radiocarbon dated to Cal 1300 CE - 1415 CE.

METHODS

The skeletal remains were examined macroscopically and with radiographic imaging. A differential diagnosis was conducted following established protocols.

RESULTS

The individual was estimated to be a probable adult female. Periarticular erosive lesions involving multiple synovial joints, particularly on the small joints of the hands and feet, were observed.

CONCLUSIONS

A differential diagnosis identifies lesions characteristic of rheumatoid arthritis dating prior to the mid-15th century.

SIGNIFICANCE

The significance of this diagnosis is great since researchers debate the antiquity and spread of rheumatoid arthritis. Some researchers hypothesize that RA originated in the Americas and spread to Europe after the mid-15th century. However, this study asserts that RA existed in Europe prior to European colonization of the Americas.

LIMITATIONS

Only 30-40 % of the skeletal material was excavated, potentially impacting the differential diagnosis.

SUGGESTIONS FOR FURTHER RESEARCH

This case encourages researchers to explore the presence of RA in other medieval groups within and beyond Transylvania as a means to reconstruct the antiquity and geographical distribution of the condition.

Big Epidemiology: The Birth, Life, Death, and Resurgence of Diseases on a Global Timescale

Big Epidemiology represents an innovative framework that extends the interdisciplinary approach of Big History to understand disease patterns, causes, and effects across human history on a global scale. This comprehensive methodology integrates epidemiology, genetics, environmental science, sociology, history, and data science to address contemporary and future public health challenges through a broad historical and societal lens. The foundational research agenda involves mapping the historical occurrence of diseases and their impact on societies over time, utilizing archeological findings, biological data, and historical records. By analyzing skeletal remains, ancient DNA, and artifacts, researchers can trace the origins and spread of diseases, such as Yersinia pestis in the Black Death. Historical documents, including chronicles and medical treatises, provide contextual narratives and quantitative data on past disease outbreaks, societal responses, and disruptions. Modern genetic studies reveal the evolution and migration patterns of pathogens and human adaptations to diseases, offering insights into co-evolutionary dynamics. This integrative approach allows for temporal and spatial mapping of disease patterns, linking them to social upheavals, population changes, and economic transformations. Big Epidemiology also examines the roles of environmental changes and socioeconomic factors in disease emergence and re-emergence, incorporating climate science, urban development, and economic history to inform public health strategies. The framework reviews historical and contemporary policy responses to pandemics, aiming to enhance future global health governance. By addressing ethical, legal, and societal implications, Big Epidemiology seeks to ensure responsible and effective epidemiological research and interventions. This approach aims to profoundly impact how we understand, prevent, and respond to diseases, leveraging historical perspectives to enrich modern scientific inquiry and global public health strategies.

Past, present and imaginary: Pathography in all its forms

Diagnosis is a profoundly social phenomenon which, while putatively identifying disease entities, also provides insights into how societies understand and explain health, illness and deviance. In this paper, we explore how diagnosis becomes part of popular culture through its use in many non-clinical settings. From historical diagnosis of long-deceased public personalities to media diagnoses of prominent politicians and even diagnostic analysis of fictitious characters, the diagnosis does meaningful social work, explaining diversity and legitimising deviance in the popular imagination. We discuss a range of diagnostic approaches from paleopathography to fictopathography, which all take place outside of the clinic. Through pathography, diagnosis creeps into widespread and everyday domains it has not occupied previously, performing medicalisation through popularisation. We describe how these pathographies capture, not the disorders of historical or fictitious figures, rather, the anxieties of a contemporary society, eager to explain deviance in ways that helps to make sense of the world, past, present and imaginary.

Generalized dermatitis in the natural mummy of the Roman Catholic nun Marie-Léonie Martin (France, 1863-1941)

OBJECTIVE

To document skin lesions on a mummified individual from the XIX century and to diagnose the pathology based historical documentation and physical examination.

MATERIALS

Marie Leonie Martin (1863-1941) was a Roman Catholic nun. Her naturally mummified body is currently preserved in the Monastery of the Visitation in Caen (France). On the occasion of her beatification, the body was exhumed, studied and restored for conservation purposes.

METHODS

The mummy was analyzed histologically and with CT imaging.

RESULTS

The examination of the body noted areas of skin discoloration of reddish color; the paleopathological investigations revealed the presence of skin lesions (pustules) distributed throughout the body, with the exception of the face, abdomen and palms. The histological analyses of the pustules showed the presence of a central duct for the leakage of exudate, hyperkeratosis of the stratum corneum and a proliferation of cells in the spinous layer (acanthosis) of the epidermis.

CONCLUSIONS

The red discoloration of the skin is typical of extensive erythema.

SIGNIFICANCE

Our understanding of skin conditions in the past is extremely limited. This study provides the first paleopathological case of diagnosed unclassified endogenous eczema and provides insight into the antiquity and effects of the disease.

LIMITATIONS

It was not possible to carry out a genetic analysis due to DNA contamination of the mummy.

Remembering St. Louis individual-structural violence and acute bacterial infections in a historical anatomical collection

Incomplete documentary evidence, variable biomolecular preservation, and limited skeletal responses have hindered assessment of acute infections in the past. This study was initially developed to explore the diagnostic potential of dental calculus to identify infectious diseases, however, the breadth and depth of information gained from a particular individual, St. Louis Individual (St.LI), enabled an individualized assessment and demanded broader disciplinary introspection of ethical research conduct. Here, we document the embodiment of structural violence in a 23-year-old Black and/or African American male, who died of lobar pneumonia in 1930s St. Louis, Missouri. St.LI exhibits evidence of systemic poor health, including chronic oral infections and a probable tuberculosis infection. Metagenomic sequencing of dental calculus recovered three pre-antibiotic era pathogen genomes, which likely contributed to the lobar pneumonia cause of death (CoD): Klebsiella pneumoniae (13.8X); Acinetobacter nosocomialis (28.4X); and Acinetobacter junii (30.1X). Ante- and perimortem evidence of St.LI’s lived experiences chronicle the poverty, systemic racism, and race-based structural violence experienced by marginalized communities in St. Louis, which contributed to St.LI’s poor health, CoD, anatomization, and inclusion in the Robert J. Terry Anatomical Collection. These same embodied inequalities continue to manifest as health disparities affecting many contemporary communities in the United States.

An investigation into the cause of death of St. Louis Individual, a 23-year old Black or African American male who died in the 1930s, reveals evidence of structural violence and the impact of systemic racism in historically marginalized communities.

The greatest health problem of the Middle Ages? Estimating the burden of disease in medieval England

OBJECTIVE

To identify the major health problems of the Middle Ages. Bubonic plague is often considered the greatest health disaster in medieval history, but this has never been systematically investigated.

MATERIALS

We triangulate upon the problem using (i) modern WHO data on disease in the modern developing world, (ii) historical evidence for England such as post-medieval Bills of Mortality, and (iii) prevalences derived from original and published palaeopathological studies.

METHODS

Systematic analysis of the consequences of these health conditions using Disability Adjusted Life Years (DALYs) according to the Global Burden of Disease methodology.

RESULTS

Infant and child death due to varied causes had the greatest impact upon population and health, followed by a range of chronic/infectious diseases, with tuberculosis probably being the next most significant one.

CONCLUSIONS

Among medieval health problems, we estimate that plague was probably 7th-10th in overall importance. Although lethal and disruptive, it struck only periodically and had less cumulative long-term human consequences than chronically endemic conditions (e.g. bacterial and viral infections causing infant and child death, tuberculosis, and other pathogens).

SIGNIFICANCE

In contrast to modern health regimes, medieval health was above all an ecological struggle against a diverse host of infectious pathogens; social inequality was probably also an important contributing factor.

LIMITATIONS

Methodological assumptions and use of proxy data mean that only approximate modelling of prevalences is possible.

SUGGESTIONS FOR FURTHER RESEARCH

Progress in understanding medieval health really depends upon understanding ancient infectious disease through further development of biomolecular methods.

A content analysis by bibliometry of the first ten years of the International Journal of Paleopathology

OBJECTIVES

The aim is to provide an overview of the nature of the content of palaeopathology articles in the International Journal of Paleopathology during the first ten years of publication (2011-2020), and to compare these results with those from other similar journals.

METHODS

The method used is bibliometry of International Journal of Paleopathology plus nine other periodicals publishing in the field of osteoarchaeology / palaeopathology. In these ten journals, 2513 publications in human osteology are reviewed of which 1032 are devoted specifically or substantially to palaeopathology.

RESULTS

International Journal of Paleopathology has attracted a large number of palaeopathology publications, but this has not been at the expense of extant journals. Its appearance appears to have coincided with an expansion of the discipline, and it may also act as a focus for publication for articles that would not previously have found a venue. Its output is distinctive from other journals assessed, with greater emphasis on review articles (including those focusing on method and theory in palaeopathology) and, especially, on case reports.

SIGNIFICANCE

International Journal of Paleopathology acts as a focal point for publications from diverse areas of the field. The connection with the Paleopathology Association provides a conduit by which outcomes of debates within the profession concerning future priorities for the field (e.g. development of method and theory; the status of the case report within the discipline) can be reflected in journal policy.

LIMITATIONS

Palaeopathology and other osteoarchaeology articles are published in venues other than those analysed in the current work.

A joint medico-historical and paleopathological perspective on vitamin D deficiency prevalence in post-Medieval Netherlands

OBJECTIVE

By applying a joint medico-historical and paleopathological perspective, this paper aims to improve our understanding of factors influencing past vitamin D deficiency in ten Dutch 17th to 19th-century communities of varying socioeconomic status and settlement type.

MATERIALS

Vitamin D deficiency is evaluated in 733 individuals of both sexes and all age groups: Silvolde (n = 16), Rotterdam (n = 23), Rhenen (n = 24), Noordwijkerhout (n = 27), Gouda1and 2 (n = 40; n = 59), Roosendaal (n = 51), Den Haag (n = 93), Hattem (n = 113), and Beemster (n = 287).

METHODS

Rickets and residual rickets are macroscopically assessed using established criteria. Hypotheses formulated based on medico-historical texts are investigated via multivariate statistical analysis of vitamin D deficiency prevalence.

RESULTS

Vitamin D deficiency prevalence ranges from 13.7 % (7/51) in Roosendaal to 48.1 % (13/27) in Noordwijkerhout, with an onset of < 4 years, and higher rates in cities, conforming to medico-historical texts. Patterns of child labor are likely key. In contrast, socioeconomic status did not statistically significantly influence vitamin D deficiency prevalence rates.

CONCLUSION

Systematically collected paleopathological data enabled evaluation of medico-historical texts and provided insights into the role that socioeconomic status and settlement type played on the prevalence of vitamin D deficiency.

SIGNIFICANCE

Combining medico-historical texts and large-scale paleopathological data enables disease patterning to be embedded in a comprehensive biocultural perspective.

LIMITATIONS

Comparisons may be limited by the small sample size of high socioeconomic status nonadults and some of the collections.

SUGGESTIONS FOR FUTURE RESEARCH

Analysis of more individuals and sites would improve our understanding of disease patterns.

Health at the writing desk of John Ruskin: a study of handwriting and illness

Though John Ruskin (1819-1900) is remembered principally for his work as a theorist, art critic and historian of visual culture, he wrote exhaustively about his health in his correspondence and diaries. Ruskin was prone to recurring depressive and hypochondriacal feelings in his youth and adulthood. In 1871, at the age of 52 years, he developed an illness with relapsing psychiatric and neurological features. He had a series of attacks of brain disturbance, and a deterioration of his mental faculties affected his writing for years before curtailing his career a decade before he died. Previous writers have suggested he had a psychiatric malady, perhaps schizophrenia or schizoaffective disorder. But the more obvious conclusion from a close medical reading of Ruskin's descriptions of his illness is he had some sort of 'organic' brain illness. This paper aims to give insight into the relationship between Ruskin's state of well-being and the features of his writing through a palaeographical study of his letters and diary entries. We examine the handwriting for physical traces of Ruskin's major brain illness, guided by the historical narrative of the illness. We also examine Ruskin's recording of his experiences for what they reveal about the failure of his health and its impact on his work. Ruskin's handwriting does not have clear-cut pathological features before around 1885, though suggestions of subtle writing deficits were present as early as 1876. After 1887, Ruskin's handwriting shows fixed pathological signs-tremor, disturbed letter formation and features that reflect a slow and laborious process of writing. These observations are more than could be explained by normal ageing, and suggest the presence of a neurological deficit affecting writing control. Our findings are consistent with conclusions that we drew from the historical record-that John Ruskin had an organic neurological disorder with cognitive, behavioural, psychiatric and motor effects.

Advancing the understanding of treponemal disease in the past and present

Syphilis was perceived to be a new disease in Europe in the late 15th century, igniting a debate about its origin that continues today in anthropological, historical, and medical circles. We move beyond this age-old debate using an interdisciplinary approach that tackles broader questions to advance the understanding of treponemal infection (syphilis, yaws, bejel, and pinta). How did the causative organism(s) and humans co-evolve? How did the related diseases caused by Treponema pallidum emerge in different parts of the world and affect people across both time and space? How are T. pallidum subspecies related to the treponeme causing pinta? The current state of scholarship in specific areas is reviewed with recommendations made to stimulate future work. Understanding treponemal biology, genetic relationships, epidemiology, and clinical manifestations is crucial for vaccine development today and for investigating the distribution of infection in both modern and past populations. Paleopathologists must improve diagnostic criteria and use a standard approach for recording skeletal lesions on archaeological human remains. Adequate contextualization of cultural and environmental conditions is necessary, including site dating and justification for any corrections made for marine or freshwater reservoir effects. Biogeochemical analyses may assess aquatic contributions to diet, physiological changes arising from treponemal disease and its treatments (e.g., mercury), or residential mobility of those affected. Shifting the focus from point of origin to investigating who is affected (e.g., by age/sex or socioeconomic status) and disease distribution (e.g., coastal/ inland, rural/urban) will advance our understanding of the treponemal disease and its impact on people through time.

Perimortem fracture manifestations and mortality after hip fracture in a documented skeletal series

OBJECTIVE

Unhealed hip fractures are underrepresented in the archaeological record, suggesting that better identification criteria are required. This paper evaluates whether a sample of documented perimortem hip fractures displayed classic perimortem features and which features may facilitate better identification of such fractures in the archaeological record.

MATERIALS

Ten individuals from the Robert J. Terry Anatomical Skeletal Collection with documented hip fractures and intervals of survival.

METHODS

We observed the skeletal remains macroscopically and with a Keyence VHX-2000 digital microscope at a range of 5x to 100x magnification.

RESULTS

90% of the individuals and 64% of the fragments had identifiable perimortem features; hinging was the most consistent feature. Eburnation was found in two individuals who died 13 days after sustaining a hip fracture.

CONCLUSIONS

This study underscores the importance of examining fracture margins for evidence of hinging. Eburnation may be added to the list of potential perimortem fracture identification criteria.

SIGNIFICANCE

Identifying perimortem trauma unequivocally remains challenging. Using collections with documented perimortem fractures aids in determining which criteria are most likely to appear in archaeological human bone.

LIMITATIONS

The fracture location patterning (70% intertrochanteric) may be the result of sample selection.

SUGGESTIONS FOR FUTURE RESEARCH

Further intensive comparative investigation with the Hamann-Todd Collection would elucidate patterns further.

Rare paleopathological insights into vitamin D deficiency rickets, co-occurring illnesses, and documented cause of death in mid-19th century London, UK

Growing evidence suggests that vitamin D supports immune responses to infections, autoimmune conditions and cancers, although evidence from large-scale studies is limited. There is scope to better understand how vitamin D deficiency interacted with other diseases to affect health in past groups. This study investigated paleopathological evidence and documentary records of individual cause of death to examine disease co-occurrence in a group of mid-19th century child burials from London, UK. Twenty-one percent of children had vitamin D deficiency rickets (138/642) and 36 children with rickets had an identified cause of death. Cyclical episodes of metabolic and nutritional deficiencies (rickets and scurvy) had occurred during childhood. Active rickets co-occurred with respiratory and gastrointestinal infections in a small number of children, likely reflecting vitamin D's role in supporting immune function. Consideration of the stage of the vitamin D deficiency showed that the majority of children were affected by chronic disease loads indicative of multiple episodes of illness. Reconstructions of the wider health consequences of vitamin D deficiency in past groups are dependent on recognising whether the deficiency was active or healed. The variability of diseases identified illustrates the high disease burden that affected children in this socially disadvantaged group.