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International Journal of Osteoarchaeology

Int. J. Osteoarchaeol. 8: 326340 (1998)


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.
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