Osteology

Sk27 –The individual was found to be a young adult male (18–25 years) with a stature of 168.9 ± 2.99cm (calculated from the femur + tibia). This is within the expected range of average male stature for the period of 171cm, which was calculated by Roberts and Cox [34] from 8494 individuals from 34 British sites dating from c.1050-c.1550.

There were no lesions characteristic of leprosy in the rhino-maxillary area or hands. The lesions in the feet were restricted to the distal pedal phalanges, particularly those of the hallux, which were found to exhibit porotic changes and some resorption of the distal ends as a result of the initiation of achro-osteolysis. While such changes are not normally considered to be pathognomic for the disease, similar alterations are found in a number of other individuals from the hospital cemetery who do exhibit early-stage rhino-maxillary changes (also recorded by Ortner [35] in individuals from Chichester) and have been recorded as typical for early stage leprosy in the clinical literature (Fig 2;[36]). The distal shafts of the tibiae of the individual also demonstrated evidence for remodelled periosteal lesions, with similar lesions also being found on the distal shaft of the left femur and the proximal shaft of the left fibula. These lesions form in response to inflammation or infection and can have numerous aetiologies, including trauma [37], although it has also been suggested that, where the major focus of the reactive bone is on the distal ends of the bones, a diagnosis of leprosy should be considered [35]. If the lesions in this individual are to be ascribed to leprosy, it would suggest that the soft tissue manifestations of the disease, with associated inflammation and infection, were much more developed than the bony lesions.

There was evidence for a large amount of dental calculus on the left maxillary and mandibular dentition (Fig 3). On the buccal surfaces of the teeth this had a nodular appearance and there was also evidence for calculus within the pits and furrows of the occlusal surfaces. This indicates that the calculus had not been smoothed down by the action of the cheek in normal masticatory function and that the entire occlusal surfaces of the dentition had at one point been covered by calculus. The left mandibular third molar had been lost ante-mortem and the alveolar bone was in the process of remodelling. It is possible that this tooth had been affected by dental caries that caused an amount of pain to the individual and prevented them from using the left side of their mouth during eating. The loss of this tooth allowed normal masticatory function to be restored by the time of the individual’s death (as evidenced by the removal of calculus from the occlusal surfaces, leaving traces in the inaccessible pits and furrows).

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larger image TIFF original image Download: Fig 3. Sk27 skull showing heavy deposition of calculus on the left side of the mandibular and the maxillary dentition, particularly on the latter, where it exhibits a nodular appearance (Credit: MHARP) https://doi.org/10.1371/journal.pntd.0005186.g003

However, high levels of dental calculus have also been recorded in archaeological individuals with skeletal evidence for leprosy, where it is thought to relate to a soft, pulpy hospital diet, poor dental hygiene as a result of the leprous involvement of the oral cavity (and also difficulty in using the hands to perform dental hygiene [38]), and mouth-breathing due to chronic inflammation of the nasal passages [3,39]. High levels of dental calculus are also found in modern individuals with the disease [38,40,41]. Dental calculus with a nodular appearance has been recorded in a number of other individuals from St Mary Magdalen with skeletal evidence for leprosy and was also seen in one individual with leprosy from St James and Mary Magdalene, Chichester, where it was argued to be related to paralysis of the facial muscles or loss of soft tissues of the cheek [39]. Therefore, it is possible that a similar aetiology may account for these changes in Sk27, also supporting the assertion that the soft tissue manifestations of leprosy may have been more substantial than the bony lesions would suggest.

The right maxillary central incisor showed resorption of the apical end of the root and the associated alveolar socket was shallow and porous in appearance. A number of individuals from St Mary Magdalen show evidence for constriction and abnormal development of the roots of the maxillary incisors and canines with associated shallow and porous alveolar sockets, which has been identified as leprogenic odontodysplasia [3,4]. In this case, however, the root does not show any evidence of constriction or abnormal development and the appearance is more consistent with resorption subsequent to trauma [42,43].

The individual had evidence for degenerative changes, in the form of porosity and osteophyte development, of the first and second cervical and the thoracic vertebrae, the coccyx, the acromial end of both claviculae and the anterior of the olecranon process of both ulnae. The mid-thoracic and lumbar vertebrae of the individual also had evidence for Schmorl’s nodes (depressions of the surfaces of the vertebral bodies).

There was evidence for entheseal changes, in the form of enthesophyte development, to the attachment sites for M. triceps (the muscle principally responsible for extension of the arm) on both ulnae, M. quadriceps femoris (responsible for extending the knee) on both patellae and for tendo calcaneus (responsible for plantar flexion of the foot and flexion of the knee) on both calcanei.

The attachment sites for M. deltoideus (involved in abduction, extension and rotation of the shoulder) on the right scapula and the left clavicle, for the costoclavicular ligament (responsible for stabilising the shoulder) on both claviculae, for the common extensors (responsible for extending the forearm) on the right humerus, for M. vastus medialis (involved in extending the knee) on the left femur, for M. adductor magnus (largely responsible for adduction and rotation of the thigh and involved in extension of the hip) on both femorae and for M. abductor hallucis (involved in abduction and flexion of the Hallux) and M. flexor digitorum brevis (responsible for flexion of the lateral four toes) on the left calcaneus, also showed an increase in robusticity and development when compared to other attachment sites.

The presence of degenerative changes in a young adult would seem to indicate an unusual degree of muscular and skeletal wear and tear related to increased levels of activity. That these changes do not simply reflect generalized wear and tear is supported by many studies demonstrating that an increase in the prevalence and severity of degenerative changes is strongly correlated with increasing age [44,45]. The assertion that these changes in Sk27 are related to activity patterns may also be supported by the finding that they are restricted to certain anatomical areas, namely the vertebral column, shoulders and elbows (e.g. see refs [46–48] for studies where specific patterns of degenerative changes are linked to specific activity patterns, although a number of other studies have disputed this link, [49–51]). The presence of Schmorl’s nodes, which have a complicated aetiology but are presumed to be related to compressive forces to the back, including bending and twisting while supporting a weight [52,53], may also support this interpretation, as would the presence of entheseal changes. These also have a complicated aetiology, with suggestions that they are more strongly correlated with age and sex than activity [54,55], although recent studies have also found that activity may indeed play a part in their development [56,57].

During analysis, the cranial morphology of the individual was noted as being of an unusual type and unlike other individuals from the cemetery (Fig 4). Therefore, the cranial measurements (S1 Table) were inputted into FORDISC and CRANID, with additional measurements being taken where necessary. The individual was found not to have an affinity with any of the populations contained within the program databases, which do include some from northern Europe, although not Britain. Therefore, the individual could be said not to share a physical affinity with these northern European samples, although this should not be taken as implying anything about their specific identity or origin. Populations that are poorly represented in the database include those from southern Europe and northern Africa (with the exception of Egypt), so there is a possibility that the individual could share physical cranial affinities with such populations, as his cranial morphology does bear similarities to other individuals from British archaeological populations who were also unclassifiable by FORDISC and have been suggested, on isotopic data, to originate from these areas [20]; (Stephany Leach personal communication, 2012).

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larger image TIFF original image Download: Fig 4. Frontal view of Sk27 skull, showing preservation of the anterior nasal spine and no obvious signs of facies leprosa. The appearance of the cranial morphology was notably different to other individuals in the same cemetery (Credit: MHARP). https://doi.org/10.1371/journal.pntd.0005186.g004