Infectious Diseases

Infectious diseases that can be diagnosed from skeletal material include treponematoses (in- cluding syphilis), leprosy, and tuberculosis but also lesser known diseases such as osteomyeli- tis, periostitis, and mycotic, viral, and parasitic conditions. Although there were some verte- brae in the study populations that might be indicative of tuberculosis, there was no conclusive evidence at either Casal Bertone or Castellaccio Europarco for infectious diseases other than

Casal Bertone Castellaccio Europarco

Male 19/54 (35.2%) 12/24 (50%)

Female 7/24 (29.2%) 3/7 (42.9%)

Subadult 4/48 (8.3%) 1/14 (7.1%)

Total 30/126 (23.8%) 16/45 (35.5%)

Table 5.3: Periosteal Reaction - Individual Frequencies

osteomyelitis and periostitis. Osteomyelitis is a pyogenic (pus-producing) infection of bone marrow. Bacteria, usually Staphylococcus aureus, are introduced into the bone through direct trauma or indirectly from soft tissue injuries. Osteomyelitis can be identified on bone primar- ily through endosteal bone changes, the formation of cloacae (holes through which pus drains), and the development of sequestra (small pieces of dead bone) (Ortner, 2003, p. 181).

Anything that breaks, tears, stretches, or touches the periosteum, or outer layer of a bone, causes it to create new bone, a condition known as periostitis or, more appropriately, periosteal reaction. Generation of new periosteum is easy to spot on skeletal elements because of its woven appearance, but the cause of the apposition is nearly always impossible to figure out, as it could result from anything from shin splits to infectious disease to serious skin burns. Because of the multifarious causes of periosteal reaction, it is quite commonly seen in skeletal populations. Like osteoarthritis, periosteal reaction is usually examined in terms of the skeletal elements that it affects in an individual and in a population. It remains, however, a nonspecific indicator of skeletal pathology.

Periosteal reactions are not widely reported in the Roman bioarchaeological literature. For this study, I calculated the frequency in a manner similar to osteoarthritis: by counting the number of individuals with at least one occurrence of periosteal reaction and dividing it by the total number of individuals examined. Results can be seen in table 5.3.

Slightly more males than females have indications of periosteal reaction, probably the result of the fact that males tended to engage in more activities than females in Roman society, and a low number of subadults is affected. The total frequency of periosteal reaction at Casal Bertone is lower than that of Castellaccio Europarco, indicating the latter population was more stressed

or more prone to trauma. Unsurprisingly, 73% of the periosteal lesions at Casal Bertone were on the legs, and 87% of the reactions at Castellaccio Europarco affected the legs, many of which were likely the result of clumsiness as people accidentally banged their shins and ankles.

Only one individual presented evidence of osteomyelitis, a male in his late teens from the Casal Bertone mausoleum (individual F4C). There was definite osteomyelitis of the left fifth metacarpal (figure 5.4) and the right radius, each of which presented with obvious cloacae, and possible osteomyelitic lesions of the left tibia, left fourth metacarpal, left hamate, and both calcanei. Because of the distribution of the lesions, it is possible this individual suffered from chronic osteomyelitis, which involves localized foci of infection that recur through time when triggered by physical stress (Larsen, 1997, p. 84).

Figure 5.4: Osteomyelitis

Left fifth metacarpal; Casal Bertone F4C, male, 16-20 years old

Osteomyelitis is not necessarily fatal, although the pyogenic bacteria can compromise other organ systems if they do not remain localized. The expansion of the diaphysis of the left fifth metacarpal of F4C indicates an active or recently active disease process, as there is no indication of healing or remodeling of this bone. There was no further evidence, however, of this young man’s possible cause of death.

5.1.4

Trauma

Evidence of trauma to bone, namely fractures and dislocations, was collected from both skeletal populations primarily as a way to assess whether people living in and near a major urban center were prone to problems of interpersonal violence. As with all other pathologies,

Skeleton Sex Age Trauma Side Bone(s) Affected

ET68 F 41-50 Fracture L rib, medial

ET43 M 31-40 Fracture R fibula

ET41 I Adult Compression L L1

F10A PM 51-60 Fracture L rib 2, medial

F11B M 31-40 Fracture L rib, anterior

F1C F 51-60 Spondylolysis L5

F4B F 51-60 Fracture L nasal

F6E F 51-60 Fracture R humeral neck

Fracture R rib 3-10, anterior

Fracture L rib 3-10, anterior

F7B M 16-20 Fracture R parietal T10 M 31-40 Spondylolysis L5 T18 PM 31-40 Dislocation L TMJ T21 M 16-20 Fracture R MC 4 T24 M 51-60 Fracture R MC 5 T28 F 51-60 Fracture L clavicle T40 M 21-30 Fracture R MC 1

T51A F 61-70 Fracture R radius

T51B I 0-5 Fracture two ribs, medial

T56 I 11-15 Fracture L clavicle

T59 M Adult Compression C vert

T61 PM Adult Fracture fibula

T69A M 41-50 Fracture rib, medial

Fracture L ulna

T9 I 0-5 Fracture R rib, medial

Table 5.4: Traumatic Injuries

comparatively few instances of trauma were discovered on the skeletons.

A fracture is simply a discontinuity of skeletal tissue, and it can range in severity from a minor, partial (greenstick) break to a traumatic, complete (comminuted) break. The fractures identified in the populations were almost all well-healed based on visual examination of the skeletal elements. A dislocation is the displacement of the two bones that form a joint. If the bones are not properly realigned following the injury, changes occur to the subchondral bone or to the bone adjacent to the joint (Ortner, 2003, p. 159). One individual suffered a dislocation of the left temporomandibular joint (TMJ), but otherwise no evidence of dislocations was found in the skeletal populations.

There were 24 instances of fractures in the populations of Castellaccio Europarco and Casal Bertone and a total of 21 individuals who suffered at least one traumatic injury. Individuals of both sexes and all ages present evidence of fracture, although it is unknown at what age each individual suffered the trauma. At Castellaccio Europarco, only three individuals suffered trauma out of a total of 45 individuals, or 7% of the population. At Casal Bertone, on the other hand, 19 individuals out of 126 (15%) presented evidence of trauma, over twice the frequency as at Castellaccio Europarco. Nevertheless, analysis of the proportions with Fisher’s exact test of a two-by-two contingency table did not show statistical significance of the two proportions (p = 0.20). At Casal Bertone, 11 males suffered trauma, or a total of 20% of the male population. Five females suffered trauma out of 24 examined, or 21% of the female population. Out of 48 subadults, three had evidence of trauma, or 6% of the subadult sample.

In terms of body parts most affected by trauma, ribs accounted for eight of the fractures and vertebrae for four, followed by arm and hand bones (three each) and the clavicle, leg, and head (at two each). Ribs are easily fractured during physical activity, so it is not uncommon to see healed rib fractures in a skeletal population. Two of the vertebral fractures were likely compression in nature, and two were a special case known as spondylolysis, when the inferior portion of the vertebral arch is fractured through mechanical stress on the spine and the bone does not knit back together (figure 5.5a). All of these fractures could relate to heavy use of the body in activities that require lifting, bending, or jumping, and advancing age can be a contributing factor. Fractures of the arms and clavicles might reflect use of the upper body in physical activity, and fractures of the metacarpals could present evidence of use of the hands in physical confrontation, as they are often broken in hand-to-hand combat. The two leg fractures were to fibulae, which are long, thin bones that can be broken during falls or other activities that place stress on the lateral lower leg.

The two fractures of the skull that were found could be related to interpersonal violence rather than to accidents. F7B was a young male who had evidence of a depression fracture of his right parietal. The fracture was well-healed and showed no indication of what kind of object

(a) Spondylolysis of L5 - Casal Bertone T10, male, 31-40 years old

(b) Nasal Fracture - Casal Bertone F4B, female, 51-60 years old

Figure 5.5: Fractures

struck his head. This injury could have resulted from trauma inflicted by another individual or could have resulted from an accident: a trip-and-fall episode, or an object falling onto his head from a height. The other instance of cranial trauma comes from F4B, an older woman with a healed fracture on the left lateral border of her nasal aperture (figure 5.5b). This kind of nasal fracture generally results from a forceful blow that pushes the nose to the side rather than from an impact to the bridge of the nose (Walker, 1997, p. 154). Although it is possible that F4B accidentally broke her nose, her left nasal bone could have been fractured by a severe trauma to the face (i.e., a hard punch) by a right-handed assailant. The multiple injuries sustained by F6E, particularly the ribs, might add to evidence of violence against women, but the locations of the fractures and the possible mechanics of the trauma are not as clear as F4B’s nasal injury. Finally, there is evidence that young children sustained fractures to the ribs. Although ribs can be fractured during a traumatic birth, rib fractures sustained by infants are predominantly caused by intentional injury (Bulloch et al., 2000).

Most of the fractures seen in the populations of Casal Bertone and Castellaccio Europarco can be attributed to accidental injury based on the location of the traumas and the possible mechanics behind them. Reliable identification of interpersonal violence based on healed frac- tures, however, is difficult to make. In a cross-cultural study of nonlethal cranial injuries, Phil Walker (1997) found a number of trends. Nasal fractures were the most common injury he

found, followed by frontal and parietal injuries. Males were more often affected by cranial trauma than females. The left side of the cranium was twice as likely to be affected by trauma as the right side. In comparing the two major causes of cranial fractures - interpersonal vio- lence and accidental injuries - among contemporary people, Walker (1997, p. 163) found that young and middle-aged individuals (15 to 50 years old) suffered cranial trauma largely from in- terpersonal violence. Individuals younger and older than this range more often suffered trauma because of falls. The cranial fractures suffered by F7B and F4B are therefore consistent with interpersonal violence; of course, accidental injury cannot be ruled out. The rib fractures on the female F6E and the children T9 and T51B could also have been inflicted by another per- son, although accidental falls are equally plausible. Finally, three males presented fractured right metacarpals (T21, T34, and T40). These fractures were all at approximately midshaft and healed with slight angulation of the bone, which are characteristics of so-called “boxer’s fractures” (Rogers, 1992) resulting from landing a blow with a clenched fist. Whether these men fractured their hands in punching another person, however, cannot be determined.

Several male individuals present plausible evidence of having inflicted trauma, and several females and children present plausible evidence of having had trauma inflicted on them. How- ever, more research involving identification of traumatic injuries, particularly in women and children, is needed before making blanket statements about violence in ancient Rome. Given the fact that a large percentage of the male population at Rome was likely to have been in- volved in the military at some point in their lives, it is surprising that there are so few traumatic injuries seen. Trauma has not been studied comprehensively in the published literature of Ro- man bioarchaeology, so it is unknown how the populations of Casal Bertone and Castellaccio Europarco compare to other urban and suburban sites.

5.1.5

Congenital Issues

The congenital pathologies identified on the skeletons were mostly related to the spine (spina bifida and scoliosis), but there was also one case of possible clubfoot (table 5.5). The

cases of spina bifida are straightforward, an example of which can be seen in figure 5.6a. Spina bifida, a common defect of the fusion of the vertebral arches that leaves the spinal cord unprotected, was found in three younger individuals. Modern clinical evidence indicates that a deficiency of folic acid in the gestating mother can lead to spina bifida in the fetus. It is difficult to tell the severity of this defect in the absence of connective tissue, which can mask the vertebral arch deficiency, but all three individuals do not seem to have suffered any serious complications, such as paraplegia.

Skeleton Sex Age Pathology Bone(s) Affected

ET69 M 21-30 scoliosis vertebrae

ET27 PM 16-20 bilateral clubfoot fibulae, tarsals, MTs, phalanges

ET18 F 21-30 spina bifida sacrum

F1A F 16-20 spina bifida sacrum

T53 PM 21-30 spina bifida sacrum

Table 5.5: Congenital Pathologies

Scoliosis, an abnormal lateral curve in the spine, is harder to recognize than spina bifida in the ancient skeleton because slight deformities might not be seen in disarticulated vertebrae. Only one individual from Castellaccio Europarco presented a lumbar spine whose anterior view resembled a lateral curve. As the thoracic and cervical spine appeared normal and there was no indication of asymmetrical development of, for example, the ribs, it is possible that this individual suffered instead from compression of the lumbar spine.

Individual ET27 from Castellaccio Europarco might have suffered from the congenital con- dition of bilateral clubfoot. It is difficult to distinguish between congenital conditions and those that were caused by a paralytic condition later in childhood, such as polio or multiple sclerosis. ET27’s condition was noticed first in the tarsals of each foot, five of which (calcanei, tali, nav- iculars, cuboids, and third cuneiforms) have significantly enlarged articular facets that show evidence of lipping and osteophyte formation. Both tibiae and fibulae have areas of periostitis, and the metatarsals and phalanges are all very lightweight with thinner than normal shafts. The vertebrae and pelvis appeared to be unaffected. Archaeological notes indicate this individual

(a) Spina Bifida - Castellaccio Europarco ET18, female, 21-30 years old

(b) Possible Clubfoot - Castellaccio Europarco ET27, probable male, 16-20 years old

Figure 5.6: Congenital Pathologies

was found with rows of nails at his feet, likely the remains of a type of tall Roman sandal. This individual’s gait was probably different than normal, likely affected by supination of the feet. The cause of this foot problem is unknown, but a congenital issue or a disease in childhood are possible explanations.

5.1.6

Tumors

Tumors in the human skeleton are usually the result of abnormal proliferation of bone, car- tilage, or fibrous tissue. When a tumor is localized and consists of mature bone, it is considered benign, but when its growth is unchecked by the body, it can affect other bones and is called malignant (Ortner, 2003, p. 503). Only benign tumors were found in the skeletal populations from Rome (table 5.6).

Osteomata are commonly found on skeletal remains, almost always on the skull bones, and are sometimes called button osteomata because of their shape and size. Individual T14 had an osteoma on the endocranial surface of his frontal bone. Auditory exostoses are osteomata of the external auditory meatus, the ear canal, often found in archaeological skeletons (figure 5.7a). In a study of auditory exostoses from the population at Portus and Lucus Feroniae, Manzi

Skeleton Sex Age Pathology Bone(s) Affected ET43 M 31-40 auditory exostosis left temporal

T10 M 31-40 auditory exostosis both temporals

T14 M 21-30 osteoma frontal, endocranially

T37 PM 31-40 auditory exostosis right temporal

T7 M 41-50 osteochondroma left tibia

Table 5.6: Benign Tumors in the Imperial Populations

(a) External Auditory Exostosis - Casal Bertone T10, 31-40-year-old male

(b) Osteochondroma - Casal Bertone T7, 41-50-year-old male

Figure 5.7: Benign Tumors

and colleagues (1991) found a lack of exostoses in females but a high frequency in males from Portus. They suggest that men’s habit of using public baths could have contributed to the differential development of the exostoses in the two sexes. A more recent analysis (Crowe et al., 2010) has suggested that individuals with exostoses at the Tyrrhenian coastal cities of Portus and Velia were engaged in water-related occupations, as higher than average consumption of seafood was found in a dietary analysis of these individuals.2

The three individuals with auditory exostoses from Rome were all middle-aged males. Analysis of skeletons from the cemetery at Basiliano just east of Casal Bertone indicated that

2_{Exposure to cold water cannot be seen as the exclusive etiology for auditory exostoses, however, as several} pathological conditions that affect the ear canal could result in an exostosis (Hutchinson et al., 1997).

6% of the population examined had auditory exostoses, but no criteria were provided for how this figure was calculated nor the sex ratio of the presence of the tumor (Buccellato et al., 2003). Additional analysis of skeletons from Rome is needed in order to investigate sex bias in the development of this condition.

Individual T7 presented a probable osteochondroma of the proximal tibia. An osteochon- droma is an exostosis of cartilage rather than bone, likely the result of overproduction of carti- lage during growth, and is a benign tumor. These lesions are typically found at the metaphyses of long bones, most commonly the distal femur and proximal tibia (Ortner, 2003, p. 508). The tibia of T7 was badly damaged, by either taphonomic processes or intra vitam erosion of the bone, but the location and appearance of the growth is consistent with osteochondroma (fig- ure 5.7b). Because the left leg bones were fragmentary, it is unclear if the osteochondroma affected this individual’s gait.

5.1.7

Miscellaneous Pathologies

A few additional pathologies could be identified in the two study populations, including occurrences of myostitis ossificans, abnormal fusion of the sternum, and hyperostosis of the cranium. Five individuals presented evidence of myostitis ossificans, a condition characterized by excessive bone formation by muscle tissue, often secondary to trauma. The most often af- fected skeletal locales are the insertion and origin points of the extensor and adductor muscles of the upper leg (Ortner, 2003, p. 134). The extra bone formation on the leg bones of F11B, T73, and ET43 are consistent with myostitis ossificans of the thigh muscles. ET57 has extra- neous bone on the clavicle at the origin of the deltoid muscle. One additional individual, F7B, appears to have the condition on the inferior aspect of his occipital (figure 5.8a), at the origin of the digastric muscle.3

Three individuals, two males from Castellaccio Europarco and one male from Casal Bertone,

3_{Interestingly, individual ET82, a middle-aged male from Phase 1 at Castellaccio Europarco, presented an} identical pillar of bone on the inferior occipital.

Skeleton Sex Age Pathology Bone(s) Affected

F7B M 16-20 myostitis ossificans occipital

F11B M 31-40 myostitis ossificans right tibia

T73 M 31-40 myostitis ossificans right femur

ET57 PM 41-50 myostitis ossificans right clavicle

ET43 M 31-40 myostitis ossificans left femur

ET103 PM 31-40 abnormal fusion sternum