Although studies in paleopathological literature have documented severe cases of disease and trauma that im-ply complications resulting in disability, few have ex-plored the survivability and required caretaking of physi-cally impaired individuals in prehistory (Dettwyler 1991, Gracia et al. 2009, Hawkey 1998, Keenleyside 2003, Ox-enham et al. 2009, Tilley and Oxenham n.d., Trinkaus 1983). In this paper, we utilize the “bioarchaeology of care” approach pioneered by Oxenham and Tilley (2009, n.d.) to elaborate on the relationship between a traumatic injury or illness and the survival of the afflicted individ-ual. This approach starts at the case-study level and in-corporates archaeological and cultural evidence to recon-struct the physical and social environment of an individ-ual. Modern clinical literature is then employed to assess physical ability, psychosocial health, and pain associated with the pathology and to evaluate the individual’s need for care. Care in this sense consists of food and water provisions, shelter, transportation, dressing, personal hy-giene, and nursing, among other forms of assistance. For this article, two case studies were chosen from several among those that exhibited severe patho-logical expression. With reference to prevalent pathologi-cal literature, the conditions were determined through differential diagnosis; that is, the diagnosis was ascer-tained through a process of elimination after description of observable evidence such as the modified features of the bone, the type of bone affected, and the age of the individual. With this knowledge, we can then consider the origins of the pathology as well as the implications of care over the course of the individual’s term with this affliction. This is accomplished through the use of cur-rent medical and nursing texts while operating within the biocultural framework of the Middle Eastern Bronze Age. Through this analysis, we may gain a better under-standing of the life histories and culture of the individuals who suffered severe pathological cases at Tell Abraq and

elsewhere. BIOARCHAEOLOGICAL CONTEXT The site of Tell Abraq is located on the Persian Gulf coast of the Arabian Peninsula in present-day United Arab Emirates (UAE). It was excavated between 1989 and 1998 by Drs. Daniel Potts of the University of Syd-ney and Debra Martin of the University of Nevada, Las Vegas and their team. The earliest archaeological mate-rial from Tell Abraq dates to the Arabian Bronze Age or Umm an-Nar period from 2600 to 2000 B.C. (Potts 2000b). The people of Tell Abraq enjoyed a rich diet from marine, agricultural, and terrestrial sources such fish, shellfish, camel, goat, dates, barley, and wheat (Gutierrez 1994, Potts 2000a). Exotic artifacts such as linen, hair combs, and ivory items suggest the site also played a significant role in a trade network involving areas such as Dilmun, Harappa, and Mesopotamia (Potts 2000a). The only human remains at the site were exca-vated from a sealed, circular-styled mudbrick tomb dated from 2200 to 2000 B.C. (Potts 2000a). The tomb is unique in that it is the only contemporaneous burial site that was not looted and was otherwise relatively undis-turbed. Over time as the tomb was used, a commingled burial formed as new individuals were interred atop the old, creating a bed of bone, soil, and artifacts 1.4 meters thick (Potts 2000a). The commingled nature of the re-mains creates a unique challenge for analysis because matching bones to any one individual to examine a com-plete skeleton is nearly impossible. Of the 286 adults in the population, we highlight two case studies of individu-als who suffered and survived a severe pathology and would have required aid from other individuals in the community. CASE STUDY #1

Proceedings of the Southwestern Anthropological Association, 2011 Vol. 5, Pp. 9-13 ISSN 1941-7500

Care for the Infirmed: Severe Cases of Pathology from the Bronze Age (c. 2200 B.C.) JAMIE D. VILOS AND DEBRA L. MARTIN University of Nevada, Las Vegas ABSTRACT Tell Abraq is a Bronze Age archaeological site on the Persian Gulf coast in modern day United Arab Emir-ates. At least 286 adults were buried in the tomb over a two hundred year period (2200-2000 BC), their bodies over time becoming disarticulated and commingled. Several severe cases of pathologies among the remains highlight extreme in-stances where individuals were in need of support and help from kin or other community members in order to survive and live with their injury or illness. From these examples, two case studies are presented: one individual with a healed mal-union fracture in the radius and another individual with a femur evidencing a dislocated knee. Degrees of pain and dis-ability associated with each malady are assessed by accounts in clinical literature. By integrating ancient ailments with modern medical knowledge within a biocultural context, ideas about care and empathy within the community are ex-plored. [Keywords: bioarchaeology, paleopathology, Bronze Age, Tell Abraq ]

Fractures are the most common traumatic injury, occur-ring across time, species, age, sex and activity (Zimmerman and Kelley 1982). While some fractures attributed to violent trauma can be lethal, this naturally depends on the location and severity of the break and the damage to bone and soft tissues. This case study focuses on an individual who likely endured the significant pain of a broken arm and dealt with the resulting complica-tions as it healed out of alignment. Description and Differential Diagnosis This case features a left radius comprised of four pieces fragmented post-mortem. Toward the proximal end of the bone, the diagnostic callus of a healing frac-ture can be observed. Not only can one clearly see the crooked line of the misaligned bone, but also of note is the slight anterior rotation of the radial tuberosity. Nor-mally, in the anterior view of the radius, the tuberosity faces anteromedially (White 2000). The overall condition of bone surface indicates an ongoing periosteal reaction, evidenced by the thickened, pitted surface, which may indicate a generalized infection occurring on the bone, or possibly a developing case of osteomyelitis related to the fracture. Additionally, both proximal and distal joint sur-faces display no signs of osteoarthritis. The fracture appears to have been complete and transverse or oblique in type (Galloway 1999, White 2000). Other types of fractures such as compression and spiral are eliminated from consideration, as these are ei-ther extremely statistically unlikely to occur on the radius or do not present the healing pattern as demonstrated in this bone. According to Galloway (1999), a radial frac-ture is more likely due to accidental trauma, such as a fall, rather than intentional. A fall could produce enough force on the radius as the dominant bone bracing for the fall. Accidental fractures typically result in an oblique

fracture which is what is likely to have happened to this individual (Ortner 2003). Implications While the human body is incredibly resilient and most fracture cases are nonlethal, this does not diminish the effects of caretaking efforts of those who assisted trauma patients in ancient times, such as at Tell Abraq. Waldron writes, “What is particularly noticeable about fractures that are found in skeletal assemblages is that the majority are well healed and in good alignment and few are found with signs of infection. This must indicate that there were in the general community, a number of indi-viduals who had the knowledge and the skill to treat and set broken bones, and that the community was able to care for the injured individuals during their period of recovery and recuperation” (2009:143). In this case, the pain at the time of the bone break would have been ex-cruciating. Bruising, broken blood vessels, and soft tissue damage are just a few of the immediate consequences (Waldron 2009, LeMone and Burke 2004). The muscles surrounding the break can naturally spasm, which may cause greater displacement of the broken ends of bone. Treatment for a fracture at Tell Abraq would have been much like today’s practices (Swearingen 2007). The bone must first be reduced or reset into anatomical position, which was likely to be very painful without surgery or analgesics. Then the bone is immobilized or restricted from movement to allow for healing, such as in a splint (Waldron 2009). The mal-union is a complication as a result of three possible scenarios where treatment was ineffective: First, the bone was broken and was never reduced; second, the break caused a greater dislodging of the bone and was improperly reduced; third, it was im-properly immobilized, and the ends shifted out of posi-tion. Based on the callus size, at least six weeks of heal-

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Figure 1. Anterior view of radius, case study #1.

ing had taken place before this person died (Waldron 2009). If this individual’s arm had completed healing, it would have resulted in a shortened, deformed limb. A difference of as little as two centimeters would be drastic to soft tissue connections, and this individual would have to become familiar with new mechanics of the arm and hand (Aufderheide and Rodriguez-Martin 1998). The limb would remain functional, but used with difficulty, meaning any tasks involving the arm were limited until the bone healed and the individual became accustomed to the changed limb. Everyday routines from subsistence practices to food consumption and basic hygiene customs would have been affected. CASE STUDY #2 This next case study investigates an individual who suf-fered a possible knee dislocation. With this type of in-jury, this adult would have been dependent on other members of the community, but it is apparent that this individual continued to work out of necessity despite any discomfort that may have been experienced. The evi-dence lies in the extensive shiny and polished area of bone on the articular surface of a femur. This condition is called eburnation, and it is a diagnostic sign of advanced osteoarthritis, which is known to occur as a consequence of a poorly healed fracture or a dislocation over time (Aufderheide and Rodriguez-Martin 1998, Ortner 2003, Waldron 2009). Although dislocation of the knee is rare, complications from ligament, tendon, or muscle tears can place this joint at risk. Once a dislocation occurs and is left untreated, pain from the injured joint often ensues. Description and Differential Diagnosis This case features a left femur, with special at-tention to the inferior surface. The distinctive eburnation is observed by the smooth, polished, shiny, and depresse-darea on the medial condyle. The extent of the eburnation of this patch is beyond the normal articular surface with the tibia and displays a strange groove pattern. These grooves run anterior-posterior on the posterior portion of the condyle and then curve posteromedially to anter-olaterally (about 45 degrees) along the shape of the ante-rior edge of the condyle. Osteophytes are also observed on the marginal edges of the medial aspect as well as the intercondylar notch. This groove pattern indicates osteoarthritis re-lated to a traumatic event that altered the mechanics of the joint (Jurmain 1999, Waldron 2009, Rogers and Wal-dron 1995). A luxation, or a dislocation caused by liga-ment damage, is the most likely explanation of these ob-servations (Aufderheide and Rodriguez-Martin 1998, Ortner 2003). An anterior cruciate ligament (ACL) tear in particular may have complicated this dislocation. The ACL restricts rotation and forward motion of tibia, and so

may account for the angled grooves (Swearingen 2007). Ligaments in the knee are prone to tears from a variety of actions, such as falls, twisting, pivoting and overextend-ing the joint (Ortner 2003, Frontera et al. 2008). The ACL has also been shown to tear from heavy lifting and squatting while bearing weight, a practice at Tell Abraq that may have contributed to the trauma (Escamilla 2001, Meyer and Haut 2005). Implications This individual would have experienced a great deal of pain at the event of the ligament tear. Symptoms of tears are much like a broken bone, with swelling, bruising, and tenderness at the site (Swearingen 2007). Particularly with the ACL, there is even a reported pop-ping sound at the time of the tear. Modern treatment of a ligament tear, besides surgery, is the “RICE” method, short for rest, ice, compression, and elevation. It is un-known, however, what ancient treatment would have been employed outside of rest. As the soft tissues healed, this individual would have been limited in mobility. The joint would have been affected by limited range of mo-tion and ambulatory difficulty (Swearingen 2007). Cer-tainly, this individual was not completely disabled and continued to function after the incident, as eburnation

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Figure 2. Inferior view of femur, case study #2.

only occurs after years of repeated joint stress and bone on bone grinding after cartilage and other soft tissues have been destroyed or worn away. Without the support of ligaments, however, the unstable knee joint would also have contributed to pain over time. Duration and distance of travel may have changed on a daily basis and was per-haps aided by a walking stick or cane. Depending on the level of pain, this individual could have continued the practice of carrying heavy loads, like water, wood, or perhaps mud-bricks, or performed tasks while seated like weaving, cooking, or child care. CONCLUSION Care of disabled individuals in ancient populations is an emerging topic that merits a closer look. The fact that severely infected and healed broken bones at Tell Abraq exist gives testament to an individual’s survival with an ailment, something that would not have been possible without outside aid. This aid may have consisted of gen-eral support such as provisions of food and shelter as well as possible specialized nursing care as in treatment of a broken limb. These case studies reveal the nature of care and compassion of those who helped their sick and in-jured. This speaks to the character and culture of the community at Tell Abraq. They valued members who were limited in their ability to contribute or were other-wise placing a burden on the group’s resources. Although these individuals were dependent on others for support, their periods of limited activity should not be thought of in terms of impairment. Their diminished capacity to contribute to the community may have been offset by taking on other tasks or roles that were within their abili-ties. But in doing so, what is less clear is how their social status may have been impacted. In addition, the roles of caretakers may have also been socially defined. These lines of thought are useful queries to gain a better under-standing of care and compassion in the community, but without artifacts or historical evidence, there is only so much that can be inferred. This research provides a nu-anced view of ancient care through a biocultural lens, and future applications of the bioarchaeology of care ap-proach would prove valuable.

REFERENCES CITED Aufderheide, Arthur C., and Conrado Rodriguez-Martin 1998 The Cambridge Encyclopedia of Human Paleo-

pathology. Cambridge: Cambridge University Press.

Dettwyler, K. A. 1991 Can paleopathology provide evidence for

“compassion”? American Journal of Physical Anthropology 84:375-384.

Escamilla, Rafael F. 2001 Knee biomechanics of the dynamic squat exer-

cise. Medicine and Science in Sports and Exer-cise 33(1):127-141.

Frontera, Walter R., Julie K. Silver, and Thomas D.

Rizzo 2008 Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation, 2nd ed. Philadelphia: Saun-ders Elsevier.

Galloway, Alison, ed.

1999 Broken Bones: Anthropological Analy-sis of Blunt Force Trauma. Springfield, IL: Charles C. Thomas Publisher, Ltd.

Gracia, Ana, Juan Luis Arsuaga, Ignacio Martinez,

Carlos Lorenzo, Jose Miguel Carretero, Jose Maria Bermudez de Castro, and Eudald Carbonell 2009 Craniosynostosis in the Middle Pleistocene human Cranium 14 from the Sima de los Huesos, Atapuerca, Spain. Proceedings of the National Academy of Science 106(16):6573-6578.

Gutierrez, Melinda

1994 Tell-tale signs of the past. Gulf Weekly 17:10-15.

Hawkey, Diane E.

1998 Disability, compassion and the skeletal record: using musculoskeletal stress markers (MSM) to construct an osteobiography from early New Mexico. International Journal of Os-teoarchaeology 8:326-340.

Jurmain, Robert

1999 Stories from the Skeleton: Behavioral Reconstruction in Human Osteology. Amster-dam: Gordon and Breach Publishers.

Keenleyside, Anne

2003 An unreduced dislocated mandible in an Alaskan Eskimo: a case of altruism or adap-tation? International Journal of Osteoarchaeol-ogy 13:384-389.

LeMone, Priscilla, and Karen M. Burke

2004 Clinical Handbook for Medical-Surgical Nursing: Critical Thinking in Client Care, 3rd ed. Prentice Hall.

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Galloway, Alison, ed. 1999 Broken Bones: Anthropological Analysis of

Blunt Force Trauma. Springfield, IL: Charles C. Thomas Publisher, Ltd.

Gracia, Ana, Juan Luis Arsuaga, Ignacio Martinez,

Carlos Lorenzo, Jose Miguel Carretero, Jose Maria Bermudez de Castro, and Eudald Carbonell

2009 Craniosynostosis in the Middle Pleistocene human Cranium 14 from the Sima de los Huesos, Atapuerca, Spain. Proceedings of the National Academy of Science 106(16):6573-6578.

Gutierrez, Melinda 1994 Tell-tale signs of the past. Gulf Weekly 17:10-

15. Hawkey, Diane E. 1998 Disability, compassion and the skeletal record:

using musculoskeletal stress markers (MSM) to construct an osteobiography from early New Mexico. International Journal of Osteoarchaeol-ogy 8:326-340.

Jurmain, Robert 1999 Stories from the Skeleton: Behavioral Recon-

struction in Human Osteology. Amsterdam: Gordon and Breach Publishers.

Keenleyside, Anne 2003 An unreduced dislocated mandible in an Alas-

kan Eskimo: a case of altruism or adaptation? International Journal of Osteoarchaeology 13:384-389.

LeMone, Priscilla, and Karen M. Burke 2004 Clinical Handbook for Medical-Surgical Nurs-

ing: Critical Thinking in Client Care, 3rd ed. Prentice Hall.

Meyer, Eric G., and Roger C. Haut 2005 Excessive compression of the human tibio-

femoral joint causes ACL rupture. Journal of Biomechanics 38(11):2311-2316.

Ortner, Donald J. 2003 Identification of Pathological Conditions in Hu-

man Skeletal Remains, 2nd ed. London: Aca-demic Press.

Oxenham, Marc F., Lorna Tilley, Hirofumi Matsumura, Lan Cuong Nguyen, Kim Thuy Nguyen, Kim Dung Nguyen, Kate Domett, and Damien Huffer

2009 Paralysis and severe disability requiring inten-sive care in Neolithic Asia. Anthropological Science 117(2):107-122.

Potts, Daniel T. 2000a Ancient Magan: The Secrets of Tell Abraq. Lon-

don: Trident Press. 2000b Arabian Time Capsule. Archaeology 53(5):44-

48.

Rogers, Juliet, and Tony Waldron 1995 A Field Guide to Joint Disease in Archaeology.

Chichester: John Wiley & Sons Ltd. Swearingen, Pamela L., ed. 2007 Manual of Medical-Surgical Nursing Care:

Nursing Interventions and Collaborative Man-agement, 6th ed. St. Louis: Mosby Elsevier.

Tilley, Lorna, and Marc F. Oxenham N.d. Survival against the odds: social implications of

care provision to a seriously disabled individual in Neolithic Vietnam. Unpublished International Journal of Osteoarchaeology.

Trinkaus, Erik 1983 The Shanidar Neanderthals. New York: Aca-

demic Press. Waldron, Tony 2009 Palaeopathology. New York: Cambridge Uni-

versity Press. White, Tim D. 2000 Human Osteology, 2nd ed. Academic Press. Zimmerman, Michael R., and Marc A. Kelley 1982 Atlas of Human Paleopathology. New York:

Praeger Publishers.

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