Penyakit Kongenital Many congenital diseases are incompatible with a normal life span, and may have led

to early death in prehistoric situations. With the onset of modern medicine, however, some of the condtions are tretable or manageable, and the patients may survive for longer. A case such as that illustrated in figure 1 would have been obviously very recognizable in life. This individual, from a modern skeletal collection, suffered from an in utero defect in the migration and closure of the first and second branchial arches which led to incomplete formation of the nose area and hypertelorism (eye wide apart). Cases like this are extremely rare, more so in countries where modern medica facilities are available. Some of the more common conditions include spina bifida, hydrocephalus, craniostenosis, and cleft palate. Spina bifida is a nonclosure of the spinal canal, where the two halves of the neural arches of the vertebrae have not fused. This ooccur most commonly in the lumbodacral area. It may be asymptomatic if small, and is then called spina bifida occulta ( figure 2). People with spina bifida may have abnormalities of the overlying skin, and sometimes also excessive growth if hair in the area. In severe cases the spinal cord is affected, resulting in neurological disorders such as paraplegia and incontinency. Hydrocephalus involves an obstruction of the flow of cerebrospinal fluid, resulting in fluid accumulation in the lateral ventricles. Since this condition usually prevails since birth, the patiens may have a very large and misshapen brain case, and in the case of young individuals the fontanelles close much later than expected, as was the case of the individuals illustrated in figure 3. This child, although abouth three years old, as judged by dentition, still had a wide open anterior fontanelle. Hydrocephalus may also be associated with other diseases of the neurological system, such as meningitis, abscesses and tumors. In the case of craniostenosis, some of the cranial sutures lose prematurely, resulting in abnormal head shapes. Premature closure of the sagittal suture, for example, will lead to an elongated head with a prominent forehead ( scaphocephaly), whereas fusion of the coronal suture produces a short skull with a very high forehead. Conditions like these would have been very noticeable during life.

Cleft palate may occur alone or in combination with a cleft lip. A Cleft palate is due to incomplete formation of the hard palate, whereas cleft lip also involves the maxilla. It may be complete or incomplete,unilateral or bilateral. In modern remains it can be expected that an attempt at some sort of reconstructive surgery would have been made.

Penyakit Infeksi A number of infectious diseases may leave signs on bones, most of which would have been of a chronic nature. It is not possible, from bones alone, to diagnose acute diseases such as gastroenteritis or pneumonia. Advanced chronic infectious disease such as leprosy and syphilis with bone involvement are seldom seen in affluent societies, although they may be more common in less-developed countries. Osteomyelitis, on the other hand, is primarily a bone disease, and sometimes becomes chronic even after treatment with antibiotics, and may therefore be seen in all societies. Acquired immunodeficiensy syndrome (AIDS), although of chronic nature, does not affect bone per se, but is often associated with other infectious diseases such as tuberculosis, syphilis, and fungal infectious of the lungs. In countries where tuberculosis is common, AIDS sufferrers often die of tuberculosis even without the AIDS being diagnosed. Periosttis of bone occurs as a reaction to pathological changes on the underlying bone. It results in new bone formation by the inner layer of the periosteum. And layers of new bone are laid down on the surface of the underlying bone. These bone deposits may be irregular and of varying thickness, often with a woven appearance ( figure 4). It may be due to infection, as in the case of osteomyelitis, or result from trauma or even in the recovery phase of deficiency syndromes (e.g.vitamin C deficiency). Periostitis is usually nonspecific, and occurs in many diseases. It may however, sometimes lead to a definitive diagnosis. In these case the distribution of the lesions may give valuble clues, as in the case of syphilis where the lesions are commonly found on bone surfaces close to the skin (e.g.anterior surface of the tibia). The term osteomyelitis generally describes infection of the bone, caused by any of a number of microorganisms. Most of these infections (80-905), however, are caused by staphylococcus aureus). Microorganisms may reach the bone (1) through the bloodstream, (2) by the extension of an adjacent infection, or (3) directly via trauma or surgery. The last two are the

most common I developed countries, where the jaws and skull are often involved due to dentl infections or sinusitis. It is also common in bones of the feet and hands in diabetic patients. Hematogenous osteomyelitis is more common in developing countries, where long bones of children and vertebrae of adults are often involved. The disease usually starts as an acute infection, but may become chronic in about 20% of the case. Hematogeneous osteomyelitis usually starts from the bone marrow, and the penetrates the endosteum. The bone cortex then becomes infected, and the infection spread to periosteum, where it may form a subperiosteal abscess. Penetration of the periosteum may cause sinus tracts (cloacae) through the cortical bone. Small or larger portions of the bone may undergo necrosis, causing a sequestrum ( fragment of dead bone). The onfection may also spread to adjacent joints, causing septi arthritis. In some cases the infection may become localized and form a chronic area of infection, which is then called a Brodies Abscess. The cronic infection may also stimulate osteoblastic activity, which results in new bone formation under the periosteum (involucrum). Bones of individuals suffering from osteomyelitis thus show bone destruction, subperiosteal new bone formation, bone deformation, sequestration, and cloacae formation. It may also lead to excessive growth of the affected bone. Osteomyelitis, is often destructive, and may lead to ankylosis of the bones of the joint. Tuberculous osteomyelitis is not commonly seen in developed countries, but may occur in compromised patients (e.g.with diabetes or AIDS). In developing countries it usually occurs in young adults and adolescents. It may be slower in onset than is the case in pyogenic osteomyelitis, but is usually much more destructive and difficult to control. It is most common in the spine and long bones where it causes extensive necrosis often resulting in sinuses that drain to the skin. When it occurs in the spine it is called Potts disease, and here it often leads to compression fractures which in turn give rise to serious deformities such as kyphosis and scoliosis. Next to spinal involvement, the hand and foot bones are commonly affected, followed by ribs, tibia and fibula. Any joint can be diseased, and this is usually associated with infection of the adjacent bones. The Knee, hip and elbow joints are most often involved. Skeletal lesions develop in less than 7% of individulas with tuberculosis.

Syphilis ( Treponema pallidum), although still a common disease in many countries, very seldom progresses to a stage where the bones are involved. There are four syndromes associated with treponemal infection ( pinta, yaws, nonveneral syphilis and veneral syphilis), although they are difficult to distinguish from each other as far as the bone lesions are concerned. Some attempts have been made to do this, mostly by looking at the frequencies of involvement of various bone. Veneral yphilis is either congenital or acquired. In the congenital form the disease is transmitted to the fetus in utero via the mother. Severe disease may develop, of which the bone lesions include periostitis and diaphyseal osteomyelitis in young children, and saber-shin deformation of the tibia, gummata on the long bones and deformation of the theeth in older children. In acquired syphilis, the tibia is most frequently involved,followed by various bones of the skull, but virtually all bones can be affected ( figure 5). This usually manifests as periostitis and / or osteitis and gummata. In osteitis the bone itself is affected, often with thickening and an irregular appearance of the whole bone. Due to the thickening of the cortex, the medullary cavities are small. Gummata form as a result of thrombosed blood vessels and toxic products of the microorganism. They vary in size, and may occur in the medulla or subperiosteally. The bone is destroyed in the region of the gummata, but the surrounding bone becomes sclerotic. Skull lesions typically involve erosion of the cranial vault by gummata and nasal-palatal destruction. Skeletal lesions occur in 10-20% of case with venereal syphilis. Leprosy is extremely rare in developed countries, but still occurs relatively frequently in poor tropical countries. Various skeletal manifestations that can be found include lepromatous osteomyelitis and perostitis, neurotrophic bone and joint lesions, and ordinary osteomyelitis due to secondary infection. As many as 50% of leprosy patients may have bone lesions. Although all bones may be affected, the face and small bones of the hand feet are most commonly diseased. In the face, the nasal bones, nasal spine and hard palate are often destroyed, and the upper incisors frequently lost ( figure 6). Bone absorption is the most common feature of the hand and foot involvement, and usually starts in the distal phalanges. Several other infectious diseases, such as brucellosis, parasitic infections and a variety of fungi may leave bones lesions, but they are relatively rare.

Degenerative Degenerative disease may also be helpful in determining the indetity of an individual. It usually occurs in older individuals. Radiographs of the diseased joint often exist, and in some cases surgical procedures, such as implantation of prostheses, may have been done. In a case from South Africa, for example, the body of an elderly individual with severe arthritis of the hip was discovered near a small town. Positive identification was easy when records of a missing person were found who was already booked in for a hip replacement. Although there are mny causes of arthritic disease, only a few can be diagnosed with the help of dry bone only. These are osteoarthritis, vertebral osteophytosis, traumatica arthritis, rheumatoid arthritis, ankylosing spondylitis, infectious arthritis and gout. Of these diseases, only osteoarthritis and vertebral osteophytosis are truly degenerative in nature. Bone change due to old age are very common, and can be seen in most people over the age of 50.Osteoarthritis is usually characterized by deterioration of the joint cartilage and formation of new bone near the joint surfaces. The subchondral bone shows irregular pits, and lipping or osteophytes form near the margins of the joint. If the overlying cartilage completely disappears, the bone is exposed. The bone may then become sclerotic with a polished (eburnated) appearance (figure 14). Weight-bearing joints, such as the hip and knee, are most commonly affected, whereas distal interphalangeal joints are also frequently affected. Although more than one joint is usually affected, the disease is not as generalized as is the case with rheumatoid arthritis. rheumatoid arthritis is an autoimmune disease. It affects many joints, including proximal interphalangeal, metacarpophalangeal, tarsal and temporomandibular joints. It occurs in younger individuals, and females are more often affected than males. Osteoporosis of adjacent bones, subluxation and ankylosis may be found. Degenerative disease of the vertebrae may involve the apophysial (facets of the vertebrae) or intervertebral joints and is characterized by osteophytes. This condition is so

common that it is unlikely to help in a positive identification. Its presence may, however, confirm that the remains are of an elderly individual.