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Activity patterns seen in the skeletal remains of an adult male (burial 391) suggest his complete dependence upon others during the progression of a debilitating disease. The severity of his condition suggests that he was wholly dependent on at least one other member of the group over a long period of time.
Activity patterns seen in the skeletal remains of an adult male (burial 391) suggest his complete dependence upon others during the progression of a debilitating disease. The severity of his condition suggests that he was wholly dependent on at least one other member of the group over a long period of time.
Activity patterns seen in the skeletal remains of an adult male (burial 391) suggest his complete dependence upon others during the progression of a debilitating disease. The severity of his condition suggests that he was wholly dependent on at least one other member of the group over a long period of time.
Disability, Compassion and the Skeletal Record: Using Musculoskeletal Stress Markers (MSM) to Construct an Osteobiography from Early New Mexico DIANE E. HAWKEY* Department of Anthropology, Arizona State University, Tempe, AZ 85287-2402, USA ABSTRACT Activity patterns seen in the skeletal remains of an adult male (burial 391) from Gran Quivira Pueblo, New Mexico, suggest his complete dependence upon others during the progression of a debilitating disease that began in childhood and lasted until his death in middle adulthood. The combination of clinical disease progression data and joint mobility estimates provide a pattern to help interpret the potential range of his movements. The pattern can then be examined in relation to results obtained from musculoskeletal stress marker (MSM) data. The MSM data for Gran Quivira 391 contrasts sharply with the activity patterns commonly seen in MSM scores for other adult males also dating to the Late Period occupation (AD 15501672) at the site. All three of the above methods not only enable assessment of the extent of his impairment throughout life, but may also provide information concerning the degree of disability within the community. Although compassion cannot always be determined from the skeletal record alone, the severity of his condition suggests that he was wholly dependent on at least one other member of the group over a long period of time. 1998 John Wiley & Sons, Ltd. Key words: musculoskeletal stress markers; disability; Gran Quivira; juvenile chronic arthritis Introduction Ethnographic studies can provide clues about community attitudes toward physical impair- ment. However, attempts to determine the de- gree of impairment (and resultant disability) from the skeletal evidence alone are problem- atic, and the assumption that the survival of such an individual provides evidence of compas- sion has been challenged [1]. Activity patterns interpreted from musculoskeletal stress markers (MSM) of an adult male (burial 391) from Gran Quivira Pueblo, New Mexico, suggest complete dependence on at least one individual during his life. Palaeopathological analysis (Table 1) sug- gests that he suffered from a systemic form of juvenile chronic arthritis, a debilitating condi- tion that began in childhood and lasted into adulthood until his death. But before the degree of impairment can be assessed, it is first necessary to establish signs and timing of the disease, and then estimate if Table 1. Osseous expressions typical and atypical of juvenile rheumatoid arthritis (JRA) as noted in the clinical literature [2,4,7,912] and present in Gran Quivira 391 Skeletal expressions consistent with JRA Growth disturbance of the long bones, resulting in premature epiphyseal closure Antegonial notching of the mandible, deformity of mandibular condyles Symmetrical involvement of more than four joints Bony ankylosis of major joint complexes, also seen in small peripheral joints Pencil-in-cup appearance of the articular ends of the hand phalanges Boutonniere deformity of the thumb Enlarged, osseous lesions at the joints A lack of involvement at the cartilaginous joints A minor degree of atlanto-occipital subluxation Skeletal expression atypical of JRA Bony ankylosis of hips and thoracolumbar region Lack of extensive involvement of cervical vertebrae Tarsal joint involvement * Correspondence to: Department of Anthropology, Arizona State University, Tempe, AZ 85287-2402, USA. Tel.: +1 602 9655016; e-mail: hawkey@asu.edu CCC 1047482X/98/05032615$17.50 1998 John Wiley & Sons, Ltd. Received 24 October 1997 Revised 10 March 1998 Accepted 24 May 1998 Disability, Compassion and Skeletal Record 327 his movements had been restricted during dif- ferent stages of his life. A predictive activity pattern can then be proposed and MSM data can be used to test the pattern. Once the degree of impairment is established, the extent of dis- ability for Gran Quivira 391 within his commu- nity can be compared with the typical range of activities observed in the MSM patterns of other adult males of the same time period. Juvenile chronic arthritis The pattern of skeletal involvement in Gran Quivira 391 indicates he suffered from juvenile chronic arthritis (JCA), a general term favoured by Resnick and Niwayama [2] that includes arthritic conditions of unknown etiology that begin in childhood. Histological analysis of this specimen [3] supports the early age onset of the condition, which may include juvenile-onset rheumatoid arthritis (JRA) in its systemic form (Stills disease), and juvenile-onset ankylosing spondylitis (JAS). Although the two conditions are difficult to differentiate clinically [4], JRA may either be a variant of JAS [5,6] or may co-exist in individuals with JAS [7,8]. Several alternative conditions were considered in my initial examination of Gran Quivira 391, includ- ing Reiters syndrome, psoriatic arthritis, and other seronegative spondyloarthropathies. How- ever, the overall pattern is consistent with the conditions seen in the systemic form of JRA [2,4,7,912], particularly if Stills disease en- compasses both JRA and JAS. Although bony ankylosis of the thoracic and lumbar regions and a lack of extensive involve- ment in the cervical vertebrae in Gran Quivira 391 are indeed unusual in rheumatoid arthritis, it does suggest the possibility of a JRA co-oc- currence with ankylosing spondylitis. The ap- pearance of JAS is generally correlated with a high frequency of the HLA-B27 marker, particu- larly in males [2]. Although the genetic marker is typically found in low frequencies in individu- als with JRA [9], the HLA-B27 haplotype does sometimes occur in individuals with JRA, and may identify children who are at risk of con- tracting JAS [13]. In Native Americans from New Mexico, presence of the B27 allele does occur [14] with up to an estimated allele fre- quency of 0.21 in some modern groups [15]. Skeletal evidence for JRA obtained from the archaeological record in the New World is scarce, consisting of a mid-adult female from Kodiak Island [16] and a young child from Peru [17]. A variety of problems may have hindered recognition of the condition, however, includ- ing a lack of detailed description of the short bones of the hands and feet, crucial in assess- ment of most forms of rheumatoid arthritis. It is only within the twentieth century that rheuma- toid arthritis has even been considered a sepa- rate entity from other forms of degenerative joint diseases [13]. In fact, New World rheuma- toid arthritis may be a recent variant of ankylos- ing spondylitis, a condition whose antiquity is established in both the Old [6,12,13,18,19] and New World [12,13,2022]. Materials and Methods Burial 391 was recovered from Mound 7 at the pueblo site of Gran Quivira (Las Humanas), located in the Rio Grande region of central New Mexico. His death appears to have oc- curred during young-middle adulthood, an esti- mate based primarily on degree of dental wear, amount of secondary dentine, and the presence of calculus deposits at the cementoenamel junction on all third molars. Although ectocra- nial suture closure had begun, no closure of endocranial sutures had occurred. The pubic symphyses could not be used to assess age at death due to pathology present in the innomi- nates. Four age categories were used to evaluate disease progression: 1) childhood (up to age 16 years), 2) juvenilesubadult (1620 years), 3) young adult (2130 years), and 4) middle adult (3140 years). A complete understanding of disease process from skeletal remains alone is difficult to accom- plish, but a combination of skeletal indicators (i.e. progressive effect of the disease, joint mo- bility range, MSM data) may provide a possible scenario for changes that occurred in the life- time of Gran Quivira 391. As summarized in Table 1, JRA (Stills disease) is most consistent with the skeletal pathology observed in this 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) D.E. Hawkey 328 individual. Stills disease exhibits very distinct stages in living individuals [2,4,7,912]: 1) the synovial membrane of the joint first becomes inflamed. Movements are painful and the joint is often involuntarily immobilized, contributing to osteoporosis in the affected region. 2) Forma- tion of pannus (a layer of granulation tissue) then occurs, followed by destruction of the articular cartilage and subchondral bone. 3) The pannus soon fills the joint space, and sizeable soft tissue cyst-like formations often appear in the weight-bearing regions of the body. These cysts can either contribute to joint destruction by having an erosive lytic effect on the cortex or can manifest itself as large, expanded osseous cysts. 4) The inflammation subsides, although fibrous adhesions and non-osseous ankylosis oc- curs, eventually causing subluxation and muscle flexion contracture. 5) The fibrous adhesions can then ossify into bony ankylosis of the joint. Given the disease pattern noted above in living individuals, it is probable that Gran Quivira 391 may have followed a similar pro- gression pattern. Thus, it is expected that the skeletal manifestations of the disease would have occurred in the order that the clinical literature suggests: 1) osteoporosis, 2) osseous erosion of subchondral bone, 3) appearance of lytic lesions on cortical bone and/or presence of osseous cysts, and 4) bony ankylosis of the joints. By inference, the type and degree of skeletal involvement can be used to clock the sequence of disease progression. For example, in Gran Quivira 391, all joints in the hips were completely ankylosed at the time of death, al- though the knees were at an earlier stage (os- seous cyst formation); movement was impossible at the hip joint, although there may have been limited mobility in the knees. Next, a general estimate of joint mobility was determined for each age category. Every joint complex (with the exception of absent skeletal elements from the sacrum, most right and left tarsals/metatarsals/pedal phalanges) was visually inspected and scored, with a total possible score per joint based on degrees of movement possi- ble. For example, there are three degrees of movement present at the glenohumeral joint (flexion/extension, abduction/adduction, rota- tion) [23]. I assigned one point for each degree of movement; if flexion alone was possible, the joint complex was assigned a score of 0.5, but if all motions were possible, a total score of 3.0 was given. Estimation of mobility was based on a number of factors, including presence and degree of ankylosis, osteophyte development, and ligamentous ossification. The values ob- tained allowed for quantification of mobility loss at each stage of disease progression. Data were then collected for presence (de- gree and type) of musculoskeletal stress markers, defined as any non-pathological marking that occurs at a muscle, ligamentous, or tendinous attachment site. I have based my scoring system [2426] on the earlier method of Angel and co-authors [27], who utilized a progressive se- ries of plus marks to indicate the relative degree of muscle insertion hypertrophy observed on bone. While this was the first attempt to stan- dardize a scoring system, Angel et al. cautioned that their system relies for its accuracy mainly on the experience of the observer [27]. In an attempt to help lessen the need for extensive observer experience, and to enhance comparability of intra- and inter-observer re- sults, I have utilized a series of photographs, accompanied by a written description, for three main categories [2326]: robusticity, stress-in- duced lesion, and ossification. Within each of the categories are three grades (from absent =0 to strong=3) representing consistent break- points at which the majority of observers agree in both inter- and intra-observer comparison tests [26,2835]. Two distinctions made within the robusticity (hypertrophy of attachment) category include muscle-to-bone (Figure 1) and tendinous inser- tion (Figure 2) sites. Muscle-to-bone attach- ments require a slightly larger area of attachment to prevent rupture when stressed, primarily due to lower tensile strength of muscle when compared to tendon. The tendinous inser- tions are affected by layers of hyaline cartilage between the tendon and bone, preventing re- sorption or formation of new bone, although the surrounding areas do reflect the stress of muscular pull. Stress-induced lesions have an irregular, lytic-like appearance (Figure 3) and may be the result of continual microtrauma at the insertion site [24], delaying the healing 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) Disability, Compassion and Skeletal Record 329 Figure 1. Robusticity scores at the pectoralis major insertion site [2426]. Scores from left to right are, a) absent: no marking is seen. b) R1=faint: the cortex is only slightly rounded, and often not visible without viewing under strong light. The elevation is palpable, although no distinct crests or ridges have formed. c) R2=moderate: the cortical surface is uneven, with a mound-shaped elevation that is easily observable. No sharp ridges or crests have formed. d) R3=strong: distinct, sharp crests or ridges have formed. process, and ultimately resulting in a necrotic appearance of remaining bone. The ossification category (Figure 4) is due to abrupt macro- trauma, creating a bony exostosis where tissue and/or ligaments ruptured and later ossified. Analytical categories in this scoring system are based on personal observations of more than 1500 skeletons from broad temporal and cultural periods throughout the southwestern United States, Canada, the Aleutian Islands, Africa, In- dia and Europe. This tripartite system of scoring MSM variation has been used for the past 10 years, with some degree of modification [26,2835]. Categories are broadly defined to accommodate the variety of factors involved in bone remodelling, including differing biome- chanical stress due to age and sex differences, individual variation in attachment, hormonal in- fluences, and type of muscle attachment. Due to the range of variation in individual size and expression of muscle markings, the categories present ranked rather than interval data. Thus, an increase in numerical value within a category represents an approximate increase in degree of MSM expression and mus- cle use. By utilizing the data in this manner, statistical comparisons can be made within and among categories, and replicability of results can be addressed. All three categories are recorded separately, although occasionally two categories may be scored for the same attach- ment site. The strongest grade robusticity score (R3) and faintest stress lesion (S1) have often been found to occur at the same attachment site within an individual, and may represent a con- tinuum between the two categories [24,25]. Results and interpretations of mobility estimates Childhood (less than 16 years old) During this period, Gran Quivira 391 main- tained full mobility of all joints (Table 2), and there is no skeletal evidence that he suffered any unusual childhood illness prior to this stage. Healed porotic hyperostosis along the coronal and sagittal sutures was evident, although this condition is not uncommon among Gran 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) D.E. Hawkey 330 Figure 2. Robusticity scores (tendinous attachment type) at the biceps brachii insertion site [2426]. Scores from left to right are, a) R1=faint: there is a slight indentation at the site of attachment, but no well-defined surrounding margin of bone. b) R2=moderate: roughening of the attachment site occurs, most often with well-defined surrounding margin of bone. c) R3=strong: deep indentation occurs with a clearly defined margin of bone. Usually the roughened area has developed crests of bone. Quivira children of the time period [36]. The characteristic prodromal symptoms may have begun, since the initial onset of JRA rarely occurs after age 16 years [37]. The majority of JRA cases in males begin in the systemic form [38], so early symptoms of high fever, malaise, anorexia, anemia, and morning stiffness of joints may have occurred by this time. While symp- toms are clinically known to subside after a 6-month period [14], episodes of JRA have been known to last for a few weeks to months, or even as long as years, often exacerbated during colder winter months [39]. There are often periods of sustained remission that may occur during the juvenile period, only to intensify during adult- hood, causing the first instance of noticeable deformity [40]. Juvenile subadult (1620 years old) The age at which the next stage occurred is difficult to determine, although the onset of the disease probably began no later than 17 years of age. In living individuals the epiphyses of the long bones close prematurely, and this cessation of long bone growth in combination with greatly atrophied bones, is known as rheumatic dwarfism [2,9,10,38]. The atrophy and greatly shortened long bone lengths of Gran Quivira 391 suggest a similar pattern in early epiphyseal union. The mandible also reflects this growth cessation, exhibiting a micrognathic appearance with antegonial notching and obtuse angle to the rami, expressions typically found in JRA [2]. In addition, the left temporomandibular joint (fossa and condyle) is malformed, with the left temporal fossa considerably smaller than the right side. By this stage there was an estimated 17% mobility loss. Muscle flexion contraction and the resultant bony fusion of the hip (Figure 5), elbow and wrists (Figure 6) had occurred, precluding any further movements in these regions. Ankylo- sis of the hip joints in a flexion contracture may have been related to an attempt to minimize intense pain; involuntary hip joint flexion is often noted in children suffering from JRA, because this position provides some relief [41]. 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) Disability, Compassion and Skeletal Record 331 Figure 3. Stress-induced lesion scores at the pectoralis major insertion site [2426]. Scores from left to right are, a) S1=faint: a shallow furrow, a pitting ( B1 mm in depth) into the cortex with a lytic-like appearance. b) S2=moderate: pitting is deeper ( \1 mm, but B3 mm in depth) and covers more surface area. It may vary in length, but never \5 mm. c) S3=strong: pitting is marked, and \3 mm in depth, and \5 mm in length. Gran Quivira 391 still maintained complete mobility at both glenohumeral joints, the tem- poromandibular joint, and both knees and an- kles, with little significant effect to the vertebral column. The third digit of each hand was com- pletely fused at the metacarpophalangeal (MCP) joint, with the proximal interphalangeal (PIP) joint ankylosed in a slight palmer contraction. All other MCP joints recovered during excava- tion indicated that limited flexion was possible, with the first digit of the right hand exhibiting a boutonniere [2] deformity (flexion at the MCP joint and hyperextension at the PIP joint). Young adult (2130 years old) A loss of mobility in the thoracolumbar region appears to have occurred. By this time, Gran Quivira 391 may have lost as much as 44% joint mobility with most movements significantly cur- tailed. Although it is uncertain when in adult- hood these problems occurred, these particular symptoms usually appear in the earlier, rather than later course of the disease (B.M. Roth- schild, personal communication, 1997). He may have been affected by spinal scoliosis (elonga- tion of cervical/thoracic spinous processes, asymmetrical development of ribs), at the be- ginning of adulthood; one instance in the clini- cal literature notes scoliosis occurred in an adult with JRA [42] Ossification of the T2T5 flavian ligaments into auxiliary pseudojoints made lateral move- ments more difficult. There is evidence of pit- ting on the T6T9 apophyseal facets, along with general osteoporosity of all elements in the thoracolumbar region. Bony ankylosis of apo- physeal facets occur from the inferior T9 to superior L3. Extensive osteoarthritis, along with ossification of the flavian ligaments into a small pseudojoint at the L3L4 articulation, would have enabled some limited flexion/extension. From L1 to L3 there is ventral collapse of the intervertebral disc space, and both L2 and L3 exhibit initial ankylosis of the ventral vertebral bodies. Complete ankylosis of apophyseal facets and vertebral bodies of L4 (inferior) to S1 (superior) was noted, but without the remainder of the sacrum below S1 (not recovered during excavation), it is impossible to know if all sacral elements were ankylosed. Loss of lower back movement would have made sitting upright im- possible without assistance. 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) D.E. Hawkey 332 Figure 4. Ossification scores at various attachments sites on the humerus [2426]. Scores from left to right are, a) Os1=faint: a slight exostosis occurs, usually rounded in appearance, and extends B2 mm from the cortical surface. b) Os2=moderate: there is a distinct exostosis, varied in shape, that extends \2 mm, but B5 mm from the surface of the cortex. Two examples are depicted of c) Os3=strong: The exostosis extends \5 mm from the surface of the bone, or covers an extensive amount of cortical surface. Middle adult (3140 years old) Joint mobility may have decreased to nearly 50%, and was limited to the head, neck, shoul- ders and flexion of the hand phalanges. In addition, large, expansive osseous lesions had now affected both knees and ankles. The knees were locked into a flexed position, and the left patella was osteoporotic and fused to this bony mass. Except for the five right metatarsals (which also exhibited similar osteoporosis and osseous lesions) the remainder of the feet were so poorly preserved that they disintegrated dur- ing excavation. A portion of the right fifth metatarsal was ankylosed to the cuboid. Enlarged, cyst-like lesions billow out at both the knee and ankle joints. Femoral mid-shaft diameters are extremely small (1212 mm) but balloon out to a maximum of 72 mm at the distal ends (Figure 7). The medullary cavity at femoral mid-shaft (measured from a thin sec- tion) is almost non-existent with only a 2 mm maximum diameter. Similar observations were made for the lower leg, where the left fibula is even more atrophied (11 mm mid-shaft di- ameter) than the right (47 mm diameter). The glenohumeral joints began to show os- teoarthritic pitting on the articular surface of both humeral heads and the corresponding glenoid fossae, probably due to excessive com- pensatory use placed on this joint. Several other conditions were present in Gran Quivira 391 at the time of death, but it is impossible to estimate the age at which they first appeared. The cervical region displays a minor degree of atlanto-occipital subluxation, slight elongation of the C2 odontoid process, and slight ossification of the C1 anterior liga- ment. Both orbits and malars are asymmetrical and disproportionate in appearance (Figure 8), with the right side noticeably larger than the left. Evidence of trauma occurs on the left side of his facea large, remodelled gash inferior to the left superciliary ridge, along with healed fracture of the nasal bones. There are no skeletal markers that indicate cause of death. Clinically documented causes [9,14,37] suggest a number of possibilities, in- cluding rheumatoid lung disease, spinal cord compression due to atlanto-occipital subluxa- 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) Disability, Compassion and Skeletal Record 333 Table 2. Joint mobility estimates for Gran Quivira 391, including total scores possible for each region, and scores obtained for each stage, as determined by disease progression data for right (R) and left (L) sides. A score of 0 indicates a lack of mobility Stage I Stage II Stage III Stage IV Region (total score possible) 3 3 Cranial (3) 3 3 R=7/L=7 R=6/L=6 R=7/L=7 R=7/L=7 Shoulder (14) R=0/L=0 R=0/L=0 Elbow (4) R=2/L=2 R=0/L=0 R=0/L=0 R=0/L=0 Wrist (4) R=2/L=2 R=0/L=0 R=10.5/L=8 R=10.5/L=8 R=10.5/L=8 R=19/L= Hand, right (19)/left (11) R=0/L=0 R=0/L=0 Hip (6) R=3/L=3 R=0/L=0 R=1/L=1 R=0/L=0 Knee (2) R=1/L=1 R=1/L=1 R=1/L=1 R=1/L=1 Ankle (2) R=1/L=1 R=0/L=0 R= R=11 R=10 R=11 Foot, right (11) 18 18 Vertebra, cervical (18) 18 18 39 15 Vertebrae, thoracic (39) 39 15 1.5 1.5 18 18 Vertebrae, lumbar (18) 151.0 125.5 85.0 78.0 Total points possible (151) 56% 52% Mobility possible 100% 83% tion, or septicaemia from a localized infection at one or more of the inflamed joints. Similarly, renal amyloidosis and thromboembolism should also be considered, although they also do not affect bone. Results and interpretations of MSM data The disease progression pattern described, along with joint mobility estimates, suggest that during adolescence Gran Quivira 391 had lost all mobility in the hip, elbows and wrists, but kept a minor amount of mobility in the lumbar vertebrae (8%), and some mobility in the tho- racic region (38%). The hands were not yet affected, with 73% mobility in the left (scored for 19 joint regions), and 55% in the right (scored for 11 joint regions). By young adult- hood he had lost all mobility in the knees and ankles, but the head and neck (including all the cervical vertebrae) maintained complete mo- bility, along with 86% mobility in both shoul- ders. Although the exact rate of bone remodelling is unknown, it is not unreasonable to assume that MSM scores would indicate stress placed on muscles (with the highest scores) sometime prior to middle adulthood. With this assump- tion in mind, the MSM data lend support to the activity pattern predicted by the disease progression and joint mobility estimates (Table 3). A considerable amount of movement was pos- sible in the head, shoulder, and arm regions, with the highest scores (R=3 and above, and including Os =1 and 2 categories) in the entire body for the insertion sites of masseter, pterygoideus and rectus capitus muscles, sternocleidomastoid, del - toideus, and the conoid and trapezoid ligaments. Muscles utilized in flexion/extension and rota- tion of the head appear to have been strongly stressed, with the muscles on the right side usually more pronounced than the left. Strong MSM for the platysma myoides and levator labii superioris (two of the rather poetically named muscles of melancholy) suggest his face was drawn downwards, perhaps related to the in- juries suffered in the incident of facial trauma. Unusually high scores for both the conoid and trapezoid ligamentous attachments suggest a strong degree of stress was placed on the shoulders, especially in actions limiting the rota- tion of the scapulae. In general, the right shoul- der and arm muscles were more strongly 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) D.E. Hawkey 334 Figure 5. Medial aspect of the right innominate and femur, with the femur ankylosed at almost 90 to the iliac blade. utilized than the left. High scores for muscles recruited in arm adduction, medial rotation of the arm, and flexion of the arm at the shoulder are common, although MSM evidence for arm abduction, lateral rotation and extension of the arm at the shoulder are also apparent to a slightly lesser degree. Similarly, supination/pronation, especially of the right forearm and hand (e.g. supinator, prona- tor teres, pronator quadratus) are also suggested by strong MSM scores for these muscles. Flexion of the hand at the wrist ( flexor carpi ulnaris, pronator teres) is also seen in higher MSM scores for the right side, with evidence for the flexor carpi ulnaris assisting in wrist adduction. The MSM results for the lower extremity tend to lack strong expressions, suggesting that the muscles of the hip and leg were not signifi- cantly utilized in the later stages of his life. The only markings with strong scores are those mus- cles which aid in flexion of the thigh at hip (vastus muscles, psoas-iliacus) and flexion/exten- sion of the trunk at hip (gluteus maximus, psoas-ili - acus) with some evidence for abduction of the leg at the hip joint (gluteus medius). These scores are likely related to the flexion contracture actions. Discussion By utilizing a combination of the three skeletal indicators (disease progression, joint mobility, MSM), a hypothetical scenario to explain the degree of disability for this individual may be offered (Figure 9). During adolescence, Gran Quivira 391 was not completely helpless, al- though flexion contracture and the resultant bony fusion of the hips, elbows and wrists had occurred, making movements in these regions impossible. The knees could still be bent, with the feet placed flat on the ground. Bony callosi- ties occurred on the ischia, lumbar spinous pro- cesses, and right elbow, consistent with a habitual posture of resting while in a prone position on his back. Although walking was impossible, the degree of joint mobility and strong MSM scores for the shoulder region suggest movement was possible by inching for- ward or backward in the supine position, using his right elbow/left arm and his feet to push himself along. During the latter stages of his life, movement was limited solely to the head, neck and shoul- ders, along with some flexion capability in the phalanges of the hand. Inching back-and-forth 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) Disability, Compassion and Skeletal Record 335 while on his back could still be accomplished, but would have been increasingly difficult, involving slowly dragging the body along by pushing against the ground using only the right elbow, aided weakly by the left arm. By this time, the large osseous cysts in the legs had begun to ankylose. Neither of the legs had any significant MSM other than those related (in all probability) to the flexion contracture action, with the lower extremities unlikely to have been utilized during the latter stages of his life. Conclusions Data obtained from the clinical literature, joint mobility measurements, and MSM results can help assess the degree of Gran Quivira 391s impairment and disability. Can we take these data a step further and ask if compassion was displayed towards him? Because he maintained some mobility in his head, neck, and shoulders throughout his life, he was probably capable of bringing food to his mouth. Given the severity of his condition he would have required some- one to supply him with food. Similarities in amount of occlusal wear and lack of caries between Gran Quivira 391 and inhabitants of the pueblo during this time period, suggest that he shared a similar diet with other residents. However, the strong muscle mastication scores observed in Gran Quivira 391 may indicate he consistently consumed food that was difficult to chew. It is also possible that the shortened rami and condylar deformity of his mandible may have placed unusual stress on the mastication muscles, thus creating a pattern not normally seen in other adults from Gran Quivira. It is possible that his healed facial trauma was due to interpersonal violence; an alternate ex- planation may involve a fall during the early stages of the disease, when walking was still possible, although difficult. Some form of treat- ment may have been implemented to alleviate walking difficulties. Cushing observed a condi- tion among the early Zuni known as the warps [43] (kyphosis of the spine). The common cure was to strap an individual on a straight, hard board, night and day. If Gran Quivira 391s vertebral disorders had been treated in a similar manner, the result would have been disastrous, because joint immobility would rapidly advance the ankylosis process [41], and may help explain the severely ankylosed condition of his spine and hips. His disability within the framework of society is more difficult to assess, although comparisons of the MSM data [24] with other adult males (n=32) from Late Period at Gran Quivira point out several inconsistencies. Muscle use by the majority of adult males suggests considerable stress on the extensors of the arm and forearm Figure 6. Right arm, forearm, wrist and hand, depicting anky- losis at the elbow, wrists, and aspects of the hand. The shoulder joint is unaffected. 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) D.E. Hawkey 336 Figure 7. Medial aspect of the right knee joint, exhibiting the large osseous cysts and greatly atrophied shafts of the femur, tibia and fibula. Figure 8. Frontal view of the cranium, exhibiting healed nasal fracture, remodelled (healed) gash on the left side near glabella, and asymmetrical appearance of the orbits and malars. (e.g. triceps, anconeus, subscapularis). The pattern in Gran Quivira 391, however, indicates a stronger emphasis on muscle actions consistent with movements of the scapula (especially scores from serratus anterior and pectoralis minor), and the pronators of the forearm (pronator quadratus, pronator teres). Although Gran Quivira 391 may not have been able to perform activities commonly done by others in his cohort, there is no archaeologi- cal evidence to suggest he was treated differ- ently. No other Gran Quivira skeletal remains (n=361) had osseous evidence of an impair- ment of this magnitude. Although Gran Quivira 391 was buried in a subfloor context, all other aspects of the burial (body position, orientation, grave goods) were consistent with other adult burials at the pueblo. Because subfloor burials at Gran Quivira were commonly reserved for chil- dren [44], the treatment after death suggests a certain amount of care had been given to this man, quite probably by his family. So, while the identity of, and the rationale for, his care-giver(s) remain speculative at best, the condition of impairment observed in Gran Quivira 391 indicates he was dependent on 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) Disability, Compassion and Skeletal Record 337 Table 3. MSM data results for Gran Quivira 391; robusticity scores indicated are for all muscles with scores ]grade 2. Muscle attachments listed below were scored at grade 2 or higher. Scores are indicated for robusticity (R), and ossification (Os) categories. There were no stress-induced lesions (S) observed in this individual Muscle name Origin score Insertion score Right Left Right Left Head and neck region RB2.0 RB2.0 R=3.5 R=3.0 Complexus RB2.0 RB2.0 R=2.5 R=2.5 Digastricus R=2.5 R=3.0 Levator labii superioris R=2.0 R=3.0 R=3.0 R=3.0 Masseter R=3.5 R=3.5 b RB2.0 R=2.5 Platysma myoides RB2.0 RB2.0 RB2.0 R=2.0 R=3.0 RB2.0 Pterygoideus lateralis RB2.0 R=3.0 Pterygoideus medialis RB2.0 R=3.0 R=2.0 R=3.5/Os=1 RB2.0 RB2.0 Rectus capitis anterior R=3.5/Os=1 R=2.0 Rectus capitus lateralis RB2.0 RB2.0 R=3.0 R=2.0 Rectus capitis posterior major RB2.0 RB2.0 RB2.0 R=3.5/Os=1 Rectus capitus posterior minor RB2.0 R=3.0 R=3.5 b /Os=2 R=3.0 R=3.0 R=3.5/Os=1 Sternocleidomastoid RB2.0 RB2.0 R=2.0 RB2.0 Temporalis RB2.0 RB2.0 R=2.5 R=2.5 Trachelomastoid Upper extremity a a Biceps brachii R=3.5 a R=3.5 R=3.5 b Deltoideus RB2.0 RB2.0 RB2.0 a Flexor carpi ulnaris R=3.5 a a R=2.0 R=2.0 a Latissimus dorsi RB2.0 R=3.0 R=3.5 R=2.0 Pectoralis major R=2.0 R=3.0 RB2.0 RB2.0 Pectoralis minor R=3.0 RB2.0 Pronator quadratus RB2.0 R=3.0 a R=2.5 Pronator teres a RB2.0 RB2.0 R=2.5 RB2.0 RB2.0 Serratus anterior RB2.0 RB2.0 Subscapularis R=2.0 RB2.0 a R=2.0 Supinator a RB2.0 R=2.0 RB2.0 R=2.0 RB2.0 Teres major R=2.0 RB2.0 RB2.0 RB2.0 Teres minor a a Triceps brachii R=2.5 RB2.0 Lower extremity R=3.5 RB2.0 R=2.0 RB2.0 Gluteus maximus R=3.0 R=2.0 Gluteus medius RB2.0 RB2.0 a a R=2.5 R=2.0 Iliocostalis lumborum R=3.0 R=3.5 Psoas-iliacus RB2.0 RB2.0 RB2.0 RB2.0 Semimembranosus R=2.0 R=3.0 R=3.0 RB2.0 Semitendinosus R=2.0 RB2.0 R=2.0 RB2.0 RB2.0 R=2.0 Transversus abdominis a R=3.0 Vastus muscles a R=3.5 Score Ligament name Right Left Upper extremity RB2.0 R=2.0 Conoid ligament (clavicle) R=3.0 R=3.0 Conoid ligament (scapula) R=3.5/Os=2.0 R=3.5/Os=2.0 Trapezoid ligament (scapula) a Missing data. b Slightly higher scores for one side within the same category and grade. 1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998) D.E. Hawkey 338 Figure 9. Proposed types of movement possible at juvenilesubadult and early adulthood stages, based on joint mobility estimates and MSM data. (Artwork by Karen S. Taylor.) other people over a protracted period of time. A combination of MSM indicators, joint mo- bility estimates, and clinical disease progres- sion data suggest that although severely impaired, Gran Quivira 391 was well-cared for, permitting him to survive to middle age. Acknowledgements I wish to thank the National Park Service (Tucson, AZ) for permission to examine Gran Quivira 391, and to Christy G. Turner II (Ari- zona State University), Bruce M. Rothschild (Arthritis Center of Northeast Ohio and Northwest Ohio University), and Andrea L. Buck (Arizona State University) for their many informative and helpful comments. In addition, many thanks to Karen S. Taylor, for the art- work in Figure 9. References 1. Dettwyler, K.A. 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