Arthritis

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Arthritis is a disease of the joints that includes many syndromes. The term arthritis implies an inflammatory condition of the joints, and inflammation is a major factor in several syndromes. One general category of arthritis, and its most common syndrome, is osteoarthritis. Inflammation may occur in osteoarthritis, but it is usually neither the initial nor the most significant factor. Although genetics, physiology, trauma, and other factors appear to play a role, the most important condition contributing to osteoarthritis is mechanical stress. Furthermore, the effect of stress in stimulating arthritic change is cumulative and thus the presence of osteoarthritis is highly correlated with age. There is also a strong association between the type and degree of physical stress and the severity of osteoarthritis. For example, relatively frequent but low-level stress over a long period of time probably has a different effect than severe intermittent stress (Ortner 1968; Jurmain 1977).

Because evidence of osteoarthritis is so common in archeological human skeletons, the potential for discerning different patterns of joint stress that may be linked to variation in culture exists. However, the current descriptive methodology for conducting such research is poorly developed, and most of the published observations on osteoarthritis do not permit any comparative anaylsis. In addition, mean age of population is often not carefully controlled. Because of the strong association between age and development of osteoarthritis, mean age is crucial to any comparison among populations.

Osteoarthritis of the spine has received the most systematic attention in paleopathological reports. Many surveys have found that the spine is more frequently affected than any other area of the skeleton (Brothwell 1960; Gray 1967; Gejvall 1974; Meiklejohn et al. 1984; Rathbun 1984). Other surveys, although offering no comparisons among areas of the skeleton, have noted the very frequent occurrence of spinal osteoarthritis (Meiklejohn et al. 1984; Bennike 1985), particularly among Egyptians and Nubians (Wells 1964a; Dawson and Gray 1968; Vagn Nielsen 1970).

A variant of spinal degenerative arthritis known as spondylosis (spondylitis) deformans is reported among some populations, such as the Late Stone Age inhabitants of the Baltic Coast (V. Y. Derums 1964), as well as those of Neolithic Jericho (Kurth and Rohrer-Ertl 1981), Neolithic Greece (Dastugue 1974), Third Dynasty Egypt (c. 2750-2680 B.C.; Ruffer and Rietti 1912; Ruffer 1918), and Bronze Age Latvia, USSR (c. 2000-1000 B.C.; V. J. Derums 1987).

Detecting time related trends from the many surveys of vertebral osteoarthritis remains problematic. Reports for Denmark (Bennike 1985) and Egypt (Wells 1964a) indicate no significant changes in the frequency and severity of the condition. Angel (1971a) reported that evidence of osteoarthritis of the spine in the eastern Mediterranean changed little from the Upper Paleolithic (c. 60 percent) until the Classic period, when there may have been a decline (47 percent). In a later paper, however, the estimated frequency of the disease during the Classic period (76 percent) was as high as or higher than that at previous time periods (Bisel and Angel 1985). The incidence of vertebral osteoarthritis in western Europe was reported to be higher in the Neolithic than in the Mesolithic (Meiklejohn et al. 1984).

The mixed conclusions of these surveys may be reflective of methodological problems. However, the importance of physical stress as a factor in vertebral osteoarthitis means that variability in sex roles, type of subsistence, and environmental factors is likely to be great. Perhaps a better understanding can be obtained with a detailed comparative study at the site level such as was undertaken by E. Strouhal and J. Jungwirth (as cited in Aufderheide 1985). They found that in two contemporary Nubian skeletal populations dating to c. 1784-1570 B.C., agriculturists had more spinal osteoarthritis than did hunter-gatherers.

In surveys of the incidence of osteoarthritis in other areas of the skeleton or of the overall rate of general osteoarthritis, the same methodological problems exist. However, some tentative trends have been reported. Meiklejohn and colleagues (1984) found that the overall rate of arthritis in western Europe was higher in the Mesolithic than in the Neolithic, suggesting greater biomechanical stress in the earlier period.

Cultural factors and differences in physical environment have been proposed as explanations for changes in the incidence of the disease. Rathbun (1984) found an overall decrease in osteoarthritis in Iran and Iraq from the earlier periods to the later Metal Ages, which he related to the change in economic activities accompanying urban life. He also found that the Iranian material typically showed more osteoarthritis than the Mesopotamian samples - a difference that may be related to terrain. Brothwell (1961) found that in Great Britain the joints of the upper extremities exhibited more osteoarthritis in the Neolithic period through the Iron Ages than they did in modern times. Manchester (1983) attributes this difference to much greater physical stress in the earlier periods.

Sex-related roles also seem to affect the frequency and severity of osteoarthritis. Male skeletons tend to have a higher rate of the disease than female skeletons. Bennike (1985) found this to be true for the spinal column in an Iron Age sample from Denmark. Similar findings of male skeletons were reported for Bronze Age Greece (Angel 1971b), the eastern Mediterranean during the Chalcolithic through the Hellenistic period (Bisel 1980), Egypt during the Dynastic period (Gray 1967), and Sudanese Nubia during the Second Intermediate period (Strouhal and J. Jungwirth, as cited in Aufderheide 1985).

Although greater male involvement is common, there are exceptions. In the Chalcolithic-Early Bronze Age (4000-2000 B.C.) material from Kalin-kaya in Anatolia, osteoarthritis was more common in women according to S. Bisel (1980), who attributes this to greater physical stress from hard work. Female skeletons also show more arthritis at Early Neolithic Nikomedeia in Greece (Angel 1973).

A second general category of arthritis is that of the inflammatory erosive joint diseases. This category includes such syndromes as Reither's syndrome, psoriatic arthritis, and three that are examined in this paper: rheumatoid arthritis, ankylosing spondylitis, and gout. Some syndromes of inflammatory erosive joint disease have a known association with bacterial infection of the bowel or genitourinary track. Lyme disease, for example, is initiated by a tick bite that introduces a bacteria (spirochete) into the host. If untreated, the disease produces severe erosive joint destruction in some patients. The prevailing theory is that other erosive arthropathies are probably initiated by infectious agents as well. Inflammatory erosive joint disease occurs in some people when an infectious triggering agent operates in combination with an individual's defective immune response. The major problem in inflammatory erosive joint disease is that the immune response to the infectious agent is not turned off after the triggering organisms are eliminated. Because of both the infectious and genetic/immune components in inflammatory erosive joint disease syndromes, their time depth and geographic range are of particular interest in the context of human adaptation and microevolutionary biology.

Differential diagnosis of some syndromes of inflammatory erosive joint disease in dry bone specimens is likely to be difficult. Statements in the literature attributing inflammatory erosive joint disease in an archaeological specimen to a specific syndrome should be treated with caution. Even distinguishing these syndromes from septic arthritis and osteoarthritis can be problematic in some cases.

There is currently a debate in the medical and anthropological literature on the antiquity of rheumatoid arthritis. B. Rothschild, K. R. Turner, and M. A. Deluca (1988) have argued that, in the New World, the disease has a history extending back at least 5,000 years. They further argue that rheumatoid arthritis may have been derived from New World pathogens or allergens. However, reports in the anthropological literature indicate that rheumatoid arthritis may have begun as early as the Neolithic in the Old World. Brothwell (1973) suggests the possibility of its presence in Neolithic skeletal material from Great Britain. Rheumatoid arthritis has also been reported in skeletal material from Neolithic Sweden (2500-1900 B.C.; Leden, Persson, and Persson 1985-6), Bronze Age Denmark (c. 1800-100 B.C.; Bennike 1985; Kilgore 1989), Fifth Dynasty Egypt (2544-2470 B.C.; May 1897), and Iron Age Lebanon (500-300 B.C.; Kunter 1977). A

specimen from Iron Age Sicily (300-210 B.C.; Klepinger 1979) may represent a case of erosive joint disease with skeletal manifestations including features of both ankylosing spondylitis and rheumatoid arthritis. More recently, L. Kilgore (1989) has suggested a diagnosis of rheumatoid arthritis for a case of erosive joint disease from Sudanese Nubia dated to between A.D. 700 and 1450.

As mentioned earlier, a diagnosis of rheumatoid arthritis should be viewed with caution. However, given the number of cases mentioned by different authors, it does seem that rheumatoid arthritis may be of some antiquity in the Old World. Although the assignment to a specific syndrome of inflammatory erosive joint disease may be incorrect, it seems likely that erosive joint disease was present by at least the Neolithic period. Further clarification of the antiquity of rheumatoid arthritis will have to await additional study of Old World archeological skeletons.

Another syndrome of inflammatory joint disease that occurs in archeological skeletal samples is ankylosing spondylitis. There is general agreement that this syndrome has a history extending for several thousand years (e.g., Resnick and Niwayama 1988). Skeletal evidence is reported in material from Neolithic France (Pales 1930; Torre and Dastugue 1976), Neolithic Sweden (Zorab 1961), and pre-Roman Germany (Zorab 1961). C. Short (1974) has concluded that there were 18 recorded cases in Egypt dating between 2900 B.C. and A.D. 200. G. Morlock (1986) has noted that cases of ankylosing spondylitis (as well as some severe forms of vertebral osteophytosis) have been misdiagnosed. He contends that some cases represent a syndrome of hypertrophic arthritis called DISH, whose antiquity therefore dates to pre-Roman Egypt, Greece, and Europe.

A third syndrome of inflammatory erosive joint disease, gout, is well known in ancient historical accounts. The Old Testament, in a passage dated to between 915 and 875 B.C., provides a graphic description of the painful symptoms of this disease (Resnick and Niwayama 1988). There are few good descriptions, however, of gout in ancient human remains. A mummy from a Christian cemetery in Egypt exhibits erosive destruction of the first metatarsals. Substance removed from the lesions produced a reaction typical of uric acid crystals (Elliot-Smith and Dawson 1924; Rowling 1961). In addition, C. Wells (1973) has reported a possible case of gout in a Roman period skeleton from a site in Gloucester, England.

Other syndromes of inflammatory erosive joint

Figure V.1.4. Dental caries of the upper left second molar in an adult male skull from Tomb A100N in the Early Bronze Age cemetery at Bab edh-Dhra', Jordan. (Unaccessioned specimen, National Museum of Natural History, Washington, D.C.)

disease may exist in ancient Old World human remains. The diagnostic criteria for evaluating the presence of these syndromes are now being developed and refined. We should have a better understanding of the historical dimension of these syndromes in the near future.

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