Download 2002 Reconstructing Medical Knowledge in Ancient Pompeii

J. RENN, G. CASTAGNETTI (eds.)
Homo Faber
Studies on Nature, Technology, and Science at the Time of Pompeii
© Copyright 2002 MINISTERO PER I BENI E LE ATTIVITA CULTURALI
SOPRINTENDENZA ARCHEOLOGICA DI POMPEI
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RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
MACIEJ HENNEBERG* and RENATA J. HENNEBERG**
In the year 79 A.D. Pompeii was buried under the
ashes from erupting Vesuvius. Within hours the
medium-sized Roman city vanished from the surface of
the Earth.' Several hundreds of people, who were trapped
in their houses, In public buildings, and on the streets,
died suffocated by volcanic fumes mixed with fine ash.
Then the dead were covered by the volcanic ashes along
with their material possessions. The city was forgotten
for centuries until it was rediscovered in the eighteenth
century. The first excavations of the urban area began in
1748.2
During the 250 years of excavation, an enormous
wealth of artefacts was recovered from the site. Among
commonly used objects of everyday life many medical
and surgical instruments have been recovered from
houses in Pompeii.3 Some of the instruments ha e not
changed their shape and form until today, some others
surprise us with their complexity and precision. Along
with a variety of objects, human skeletons were uncovered in various locations in the cit . Immediately the
question arises: Is there any connection between the
medical knowledge of ancient Pompeian and their health
status and quality and length of their life?
It has been estimated from existing field notes and
other documents that skeletons of just over one thou-sand
individuals were recovered over the 250 years of
excavation.4 Skeletal remain of only a half of the estimated number of individuals have survived up to today
and their state of preservation is mostly fragmentary.
Despite its fragmentary nature this skeletal material is still
one of the largest skeletal samples from the Roman era
available for study. More skeletons are slowly yet
constantly being excavated in various parts of the city
enlarging this sample.
The abundance of archaeological evidence from
Pompeii and from written sources about the Roman
times and the city itself allowed researchers to undertake
the reconstruction of many aspects of life in the city.5
While a lot is known about art, architecture, politics, the
various activities in the city, trade, technology and war-
fare, occupations and interests of its inhabitants, how
much do we really know about the people themselves
and their biology? The full reconstruction of life cannot
be attempted without the hard evidence—the study of the
human body. The reconstruction of the biological part of
human life from human skeletal and dental remains is
one of the goals of biological anthropologists.
Human skeletal remains can provide information
about demographic structure and demographic dynamics, about physical characteristics of the people and their
biological relationships, about the people's relationship
to their environment, about diseases they suffered from,
diet, hygiene, and about specific activities of individuals.
Based on the information embedded in bones it is
possible to write the history of the human body and to
reconstruct the biological life of the person and the
population.6
One of the difficulties of palaeoepidemiology is that
many serious or often deadly diseases leave no marks on
bones. Any infection that develops rapidly and quickly
resolves, either by killing its victim or by being naturally
cured, is invisible on bones that are the only remains left
to study. Chronic diseases and trauma that involved
bone will, however, be seen. Also, the infection or other
health impediment that affected a developing child may
leave their mark on the enamel of teeth that formed in
the jaws of a sick child. These enamel defects are called
hypoplasia and manifest on the tooth crown as horizontal rings of thinned enamel or as a series of pits. Thus,
the picture we can gain from analyzing pathological
conditions in skeletal samples is mostly that of chronic
diseases, trauma, and some unspecified infectious diseases and hardships during childhood. This picture is
obviously not complete but rich enough to attempt partial reconstruction.
The study of ancient populations begins with establishing their demographic structure and dynamics.
Studies of paleodemography and of paleopathology
have been carried out on many ancient and prehistoric
populations. Large skeletal samples suitable to address
ques-
*Wood Jones Chair of Anthropological and
Comparative Anatomy, University of Adelaide,
Australia.
**DepartmentofAnatomicalSciences,University
of Adelaide, Australia.
1
S IGURDSS ON ET AL.. 1 9 8 5 .
TIENNE 1 9 9 2 .
CASCINO ET AL.,1999.
4
DE CAROLIS ET AL., 1998.
5
TANZER 1939, GRANT 1971, DE
FRANCISCIS 1978, DESCOEUDRES
1994, ZAN KER 1998, CIARALLO
AND DE CAROLIS 1999.
6
LARSEN 1997.
2
3
1 7 0 MACIEJ H E N N E B E R G A N D RENATA J H E N N E B E R G
tions at the population level usually come from cemeteries where people died of natural causes such as terminal
illness, and where people were dying over long time,
measured usually in centuries. It has been argued that
the demographic structure of the population from the
"normal" cemetery does not represent the population
structure of the living people at a given time such as
examined by census takers or studied by epidemiologists. The bias, also called an "osteological paradox," 7
created in the skeletal material from cemeteries makes
studies of mortality and studies of prevalence and incidence of diseases more difficult. Paradoxically, the
after-math of past catastrophes and epidemics where
entire populations have been wiped out in a short time
creates better grounds for studying the demography.
Such events, however, are rare and accompanying
historical documentation is often poor.
Pompeii presents the unique opportunity to study
the population frozen in time, with truly "living" properties. In addition, the rich archaeological and historical
evidence makes the remains of ancient Pompeians an
ideal choice for interdisciplinary study and for creating
models for studies of less well documented archaeological skeletal samples.
In this study we describe the basic biological
proper-ties of the Pompeians and, using observations
made on bones, we try to answer the following
questions:
1) What was the effect of ancient medical practice
on the mortality and other demographic characteristics
of the population?
2) What was the ability of ancient doctors to cure
ailments as compared to the abundance of surgical
instruments found in the city?
3) Did the ancient medical knowledge have any
influence on the prevalence and incidence of diseases in
Pompeii?
MATERIAL AND GENERAL METHODS
During the years of excavation at Pompeii human
skeletal material was transported several times from one
storeroom to another. Most of the time bones were
stored in locations unprotected against the weather such
as the ruins of ancient bathhouses. Lack of proper
storage, care-less handling of the bones, and the way the
bones were excavated by earlier investigators caused
damage to about one half of the skeletal material. At one
stage, several decades ago, the skeletons were
disarticulated and bones
7
WOOD ET A L . 1 9 9 2 .
NICOLUCCI 1882.
9
See the study of the skeletal material from
the House of Julius Polybius in HENNEBERG
M. ET AL. 1 9 9 6 .
8
were sorted out by the type: skulls and mandibles put
separately on a shelf, femora on one pile, humeri on a
separate pile, pelves on another, and so on. In another
case several skeletons excavated from one sector of
the city were mixed together in one big box. Early
physical anthropologists considered skulls the only
part of the skeleton worth studying. At the end of the
nineteenth century Giustiniano Nicolucci separated a
hundred of the best preserved skulls from the rest of
the individual skeletons for the first classical
craniometric study of Pompeians.8 Such treatment of
the skeletal material, perhaps justifiable in terms of
archaeological methods of the nineteenth and early
twentieth centuries, makes it more difficult to
establish age and sex of each individual and observe
pathological conditions that often involve various
bones of the same person.
Over the years techniques of excavation have improved and, above all, attitudes towards the importance
of skeletal remains as a source of information have
changed. Today every piece of bone should be
carefully excavated and the bones of an individual
skeleton should be kept together, in its biological
context, for the maximum recovery of information. A
few more recently excavated skeletons have been
preserved this way by the Soprintendenza
Archeologica of Pompeii and allow control of the
accuracy of sexing and aging of the entire material, as
well as specific case studies.9
At present the skeletal sample consists of mostly
disarticulated and fragmentary remains of around 500
individuals and about 40 almost complete skeletons.
Due to its fragmentary nature, various forensic
methods used in investigations of mass burials along
with classical and recently developed physical
anthropological methods have been applied to study
the material. Morphological observations at the
macroscopic and microscopic level, radiology, and
statistical methods are the basic tools used in any
investigation carried out by a physical anthropologist.
Although these methods are considered classical,
further progress has been achieved in their
development and application. In addition, a variety of
chemical methods have been applied to study bone
material at the molecular level including the analysis
of ancient DNA.
Our studies of Pompeian human skeletal remains
are ongoing and attempt to cover as broad a range of
subjects of interest to biological anthropologists as
possible. Some of the results of our investigations on
data collected during the field trips in the years 19932000 are presented below.
RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
PALAEODEMOGRAPHY
In a normally functioning human
population age-specific mortality is measured
as numbers of people of a particular age
dying from the total number of people of that
age alive at the time. Knowing only numbers
of deceased is not sufficient because natural
increase and other demographic events
differentially influence numbers of people
alive in various age categories. It is only in
the situation of a stationary population, where
fertility and mortality rates are stable and
natural increase is at zero level, that numbers
of deceased in each age category will be
directly proportional to numbers of persons
alive in those age categories. Hence,
reconstructions of mortality profiles from
skeletal remains excavated from burial
grounds were criticized by demographers as
unreliable.10 The only way to test whether
ancient populations approximated the
stationary model is to compare distributions of
deceased by age obtained from "normal"
burial grounds with a distribution representing
a living population. Due to a natural disaster
during which large numbers of people were
killed within a matter of hours, Pompeii
reflects the living population. This fact allows
us to conduct a population census and an
epidemiological study of an ancient living
population.
171
Fig. 1. Pompeii. Distribution of skulls,
mandibles, and hip bones by sex and age. A line
representing age distribution in a sample of
skeletons excavated at the ancient Greek
necropolis of Pantanello (Metaponto) is added
for comparison. The rightmost two bars
indicate the number of individuals whose age
could not be determined more accurately than
simply saying that they were adults.
MORTALITY
The general mortality in a population is
studied with the aid of demographic methods.
The most common of those is the calculation
of life tables.11 These tables contain a number
of biometric functions describing probabilities
of dying at particular ages, survivorship to a
particular age, life expectancy, and structure
by age
10
BOCQUET AND MASSET 1977,
SATTENSPIEL AND HARPFNDING 1983,
BUIKSTRA AND KONIGSBERG 1985,
JOHANSSON AND HOROWITZ 1986.
11
ACSÁDIAND NEMESKÉRI 1970, WEISS1973.
172
MACIEJ HENNEBERG AND RENATA J. HENNEBERG
F i g 2. Distribution of individuals by age
at death atPompeii. Comparison between
Pompeii rural Metaponto (necropolis
of Pantanello, 6th-3rd century and
Paestum (necropolis of Ponte di Ferro,
6th-4th century B. C.).
12
KROGMAN AND ISCAN 1 9 8 6 ,
LOVEJOY E T A L . 1 9 8 5 .
of a living population. When one of these functions is
known, others can be calculated based on certain
assumptions regarding fertility and thus natural increase.
Acsádi and Nemeskéri, in their 1970 seminal and still
current monograph, provided substantial num-bers of life
tables for prehistoric and early historic populations
starting in the Epipaleolithic some 10 thousand years ago
and going into the medieval times. The only data,
however, at their disposal were derived from skeletal
materials excavated from burial grounds. Here, for the
first time we apply life table methods to a sample of
skeletons representing a living population. Although this
approach is free of the "osteological paradox," in the case
of Pompeii it encounters another problem.
We have already described that most of the skeletons
were disarticulated and bones piled up by type, thus
creating an additional problem with assessing the sex and
age of individuals. To overcome this problem as well as
possible, we have chosen elements of the skeleton
containing the majority of reliable sexual characteristics
that also allow us to observe most common signs of
aging. For the study of mortality 364 skulls, 129
mandibles, and 186 right hip bones were available. Many
of these skeletal elements were fragmentary. In order to
avoid counting the same individuals twice we have
considered as representative of a skull any fragment that
contained at least the glabellar region (a smooth
area between the two brow ridges), of the mandible
any large fragment that contained the right ramus
and molar region, of the hip bone a fragment
containing the auric-ular facet for the articulation
with sacrum and the greater sciatic notch just
below the auricular surface. Skulls, mandibles, and
pelves all display sexually dimorphic characters
and allow us to estimate the age at death by
observations of the obliteration of cranial sutures,
the state of dentition, and the changes on the pubic
symphysis and auricular surfaces.12 Accuracy of
sexing and aging varies by trait and by the state of
preservation. Sex can be reliably established for
adults only. The proportions of males, females, and
individuals of various ages estimated from each
specific skeletal element varied depending on the
reliability of diagnostic traits (fig. 1). It can be
observed, however, that each skeletal element
yielded a number of males and females distributed
similarly across age groups. Most individuals in
the sample were young adults (20-40 years old),
very few were children and a relatively small
number were seniles. This distribution seems to be
characteristic for most skeletal
RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
Table 1. Reconstructed life table for Pompeii 79 A.D.
Age (x)
d(x)
0
5
10
15
20
30
40
50
60-x
40.00
9.00
5.00
3.00
6.00
7.00
8.00
8.00
14.00
1(x)
100.00
60.00
51.00
46.00
43.00
37.00
30.00
22.00
14.00
4(x)
0.40
0.15
0.10
0.07
0.14
0.19
0.27
0.36
1.00
e(x)
24.6
34.3
34.9
33.4
30.6
24.7
19.3
14.5
10.0
d(x) = percentage dying at age x among all deceased
1(x) = survivorship to the beginning of the age category x
q(x) = probability of dying in the age category x
e (x) = life expectancy (years remaining to be lived) at the
beginning of the age category x
c (x) = proportion of persons aged x in total living population
(population pyramid), assuming zero natural increase.
samples excavated from ancient burial grounds. The
small number of skeletons of infants, children, and adolescents is the result of excavation techniques that miss
many small bones, and of the lower probability of pres-
173
ervation of small skeletons in collections that were
moved several times. Therefore the number of
subadults is biased. The age distribution of adults
reflects demo-graphic dynamics of a population. In
the case of Pompeii it can be argued that skeletons
excavated in the city are a result of deaths of those
individuals who, for various reasons, stayed behind
rather than escaping or even returned to the city
during the quieter phase of the eruption. Decisions
of these individuals may have been dependent on
their sex or age thus resulting in a biased sample of
skeletons. Our analysis shows, however, that this has
not been the case. The average ratio of adult males
to adult females, weighted by the number of bones
of each category, is 99/100 though it varies from
skulls (148/187) to hip bones (103/83) and to
mandibles (63/48) as expected from the different
diagnostic values of various skeletal characteristics.
The distribution of deceased by age is very
similar to that in other skeletal samples (fig. 2). The
only difference is the proportion of infants and
young children which is mostly an artefact of
archaeological techniques. The distribution of adults
from Pompeii by age
Fig 3. Comparison of survivorship [1(x)] in
Pompeii with model life tables, with ancient
populations from Ponte di Ferro (servants
and slaves from Paestum, Southern Italy, 6th5th century B. C.), rural Metaponto (Greek
colonists, Southern Italy, 6th-3rd century B.
C.), and nineteenth-century Central Europe.
In model life tables level I represents the worst
demographic situation with lowest
survivorship and level 24 represents the best
demographic situation where almost 100%
of people survive to 60 years of age.
1 7 4 MACIEJ HENNEBERG AND RENATA J. H ENNEBERG
13
HENNEBERG M. AND HENNEBERG 1998.
HENNEBERG M. ET AL 1 9 9 5 .
1i5
HENNEBERG M. 1976, PIONTEK AND
HENNEBERG 1981.
16
HENNEBERG M. AND HENNEBERG 1998,
HENNEBERG M. ET AL. 1 992 , HENNEBERG
M. ET AL. 1 9 9 5 .
17
COALE AND DEMENY 1966.
18
HENNEBERG M. 1976.
19
ACSADI AND NEMESKÉRI 1970.
20
ORTNER AND PUTSCHAR 1985,
AU DERHEIDE AND RODRÍGUE -MARTIN
1998.
14
does not differ significantly (KolmogoroffSmirnoff test, p<0.05) from those of two other
ancient burial grounds in Southern Italy,
Pantanello (6th-3rd cent. B.C.),13 and Paestum
(6th-4th cent. B.C.).14 Interestingly, the distribution
of adults by age in Pompeii also does not differ
significantly from that of adults dying in preindustrial Central Europe (Parish Szczepanowo,
Poland, 1828-1854).15 Two important conclusions
can be drawn from these comparisons: (1) the
skeletal sample excavated in the ruins of Pompeii
presents an age structure normal for an ancient
population and, (2) age structures of samples killed
in a disaster, thus representing a living population,
and samples excavated from normal cemeteries of
antiquity do not differ. The natural increase in
antiquity was therefore small enough not to
produce any significant deviation of real
populations from the model of a stationary
population (stable mortality and fertility, zero
growth).
Having established that the skeletal sample
from Pompeii is similar to other samples from
antiquity and pre-industrial Europe, and
remembering the under re-presentation of infants
and children due to archaeological procedures, a
complete life table for the population of Pompeii
during the first century A.D. can be approximated
(tab. 1). In this approximation we have used
previously established life tables for Southern
Italian skeletal s m 1 sl6 and the model life tables
of Coale and Demeny.17 The life table for Pompeii,
being typical for pre-industrial societies, shows
low newborn life expectancy of around 25 years,
high infant and juvenile mortality, and rather small
proportion (14%) of people surviving to old age.
These were characteristics of populations
who had no means to prevent the spread of
infectious diseases and had low levels of general
hygiene and sanitation (fig. 3). It seems that the
people of Pompeii had no effective means of
curing infectious diseases nor of controlling their
spread.
With the reconstructed life table and knowing
that the population of Pompeii was in
approximately stationary state it is possible to
reconstruct fertility. 8 In a stationary population
death rate equals birth rate while the natural
increase is zero. Death rate of a stationary
population is a reciprocal of the newborn life
expectancy's In the case of Pompeii, with newborn
life expectancy of 24.6 years, crude death rate was
about 4.1% and so was the crude birth rate.
Remembering that fertile women constituted
approximately 20% of the entire population
it can be estimated that the Total Fertility Rate
(number of children b o r n per woman surviving
to menopause) was 6 to 7 children. Less than half
of them were surviving to sexual maturity to
participate in reproduction of the next generation.
Stresses of frequent childbearing and of common
infant and child death must have left their marks
on the lives of Pompeian women.
PATHOLOGICAL SIGNS ON BONES
Only certain diseases, ailments, and
traumatic events leave their marks on bones.
Typically these are diseases and injuries of bones
and those other diseases that, through their
chronic nature, produce changes in bones
following those occurring in other tissues. The
sample of bones from Pompeii, due to its large
size, presented signs of many of the most
common ailments known to paleopathologists.20
These signs are listed by site and disease in table
2, while their sites are illustrated on figure 4.
Traumatic injuries to the skull vault and
fractures of long bones were well healed
indicating that the patients survived these injuries
by a number of years (fig. 5). This testifies to the
ability of Pompeian to provide general care of
sick people such as cleaning of the wounds, rest,
adequate nutrition, and probably basic personal
hygiene. Some of the bone fractures were well
set while others were not, producing permanent
disability. It seems that the knowledge of bone
setting of Pompeian surgeons was good, but that
this service was not available to everyone.
One of the most common pathologies was
that of the inflammation of the periosteum (tissue
covering bone surfaces) and pericranium
(equivalent of periosteum on the skull). These
most often manifested as layers of bone tissue
(reactive bone) newly formed by the periosteum
on the parietal and frontal bones of the skull and
on tibiae (shin bones), though they occasionally
occurred on other bones. Inflammation of the
periosteum (periostitis) is caused by a number of
factors. Localized mild trauma to the bone
surface may result in localized periostitis.
Similarly, periosteal reaction can accompany
larger injuries or localized bone diseases, while
generalized periostitis is a result of blood-borne
systemic infections. In this latter case, the bone
surfaces most commonly affected by the
periostitis are those covered directly by the skin
and, thus exposed to the external
RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
Table 2. Diseases and disorders of ancient Pompeian who died in 79 A.D.
Pathological sign or disease
and part of the body affected
No. of cases*
or no. of cases/no. of
individuals examined
Frequency (%)
Skull
1. Trauma (fractured skull, wound)
2. Paget's disease
3. Torticollis
4. Premature synostosis of the sutures
5. Hyperostosis frontalis interna
6. Cribra orbitalis
7. Otitis (ear infection)
8. Possible meningitis
9. Arthritis of temporomandibular joint
mandible
glenoid fossa
10. Stellate lesions
11. Button osteoma
12. Rugosity and pitting on parietals or frontal
Combination of signs In p. 10., 11., and 12.
2
3
3
2
36/348
1
1
1
1
1
1
10 (Lazer 1996)
10
<1
<1
38/108
48/201
4
15/300
23/300
5
35
24
1
5
8
5
3
1
1
1
1
2
141/365
7/365
16/149
4/149
2
1
<1
<1
<1
<1
1
39
2
11
3
1
Postcranial skeleton
1. Fractures
tibia
femur
fibula
rib
finger
2. Osteosarcoma (femur)
3. Periosteal reaction (tibia)
4. Osteoma on long bones
5. Spina bifida occulta (sacrum and L5)
completely open posterior part of sacrum
6. Congenital hip displacement
7. Arthritis (various forms)
neck:
atlas fused with occipital, dens axis
spine: diffuse idiopathic skeletal hyperostosis (DISH)
zygapophyseal joints (osteoarthritis)
vertebral bodies (osteophytosis)
elbow: humerus
radius
ulna
hands: phalanges
hip:
ass. with congenital hip displacement
lipping on femoral head
sacro-iliac joint (fused)
knee:
distal femur
proximal tibia
patella
feet:
calcaneus
metatarsals
2+
2
1+
common
5+
1+
2+
1+
2
3+
1
6+
4+
1+
1+
2+
* The systematical study of diseases in Pompeii is in progress thus the frequency of pathological signs or disorders is not available for all entries.
175
176 MACIEJ HENNEBERG AND RENATA J. HENNEBERG
Fig 4. Summary representation of the
pathological findings in Pompeii. Arrows
show the parts of the skeleton with
pathological conditions found in the
human skeletal sample stored in a
depository of the Soprintendenza
Archeologica di Pompei.
21
STEINBOCK1976,ORTNER ANDPUTSCHAR
1985.
22
HENNEBERG M. AND HENNEBERG
1994, HENNEBERG M. AND HENNEBERG
1998, HENNEBERG M. ET AL. 1992.
23
A. ìarallo, personal communication to the
authors.
environment with its fluctuating temperatures and
possibility of injuries. These are the medial surface of
the tibia and, obviously, the forehead and scalp. In Pompeii, the most frequently observed signs of periostitis
occur on tibiae (fig. 6a-b) and skull vaults. This
therefore suggests that the population was exposed to
chronic systemic infections. Among these infections,
the most common are usually tuberculosis, leprosy, and
treponemal diseases (including syphilis). To distinguish
which
of these diseases produced periosteal lesions requires
observations of their relative distribution on various
bones of the skeleton and finding other pathological
signs specific for each disease, though not as common
as periostitis.21 In Pompeii, we could not yet find any
bony signs characteristic for leprosy. Some changes
on the vertebral columns could be a result of
tuberculosis though not decisively so. On four skulls
we were able to observe stellate lesions, characteristic
for the healing of gummatous ulcers caused by
treponemal disease. These lesions were, however, not
extensive. Taking into account that from among the
three diseases treponemal infections most commonly
leave periosteitis marks on tibiae and skull vaults, and
also the fact that these changes on tibiae were more
frequently observed in Pompeii than in Metaponto22 where the presence of other specific changes,
including dental crown malformations supported the
diagnosis of veneral treponematos (syphilis) - we
may tentatively conclude that treponemal infections,
possibly of veneral, syphilitic nature were also
present in Pompeii. This conclusion is strengthened
by the fact that Pliny described the use of ointments
containing mercury for the treatment of weeping
ulcers on the forehead.23 These ulcers are a classical
manifestation of tertiary treponematosis. Our
investigation is ongoing and future studies may
produce more decisive finds and more conclusive
diagnoses.
The variety of other pathological signs on bones
shows that ancient Pompeians were victims of
diseases and deformities that still plague modern
people. We found two cases of malformed adult
femoral heads and necks indicating untreated
congenital hip displacement which would cause a
permanent limp (fig. 7). Another congenital
abnormality resulted in premature fusion (synostosis)
of the sutures separating bones of the skull vault
during growth. If one of the sutures is fused, the
brain growing inside the skull cannot expand all the
bones of the vault in a regular fashion. This results
i n asymmetrical growth of the braincase (fig. 8).
Today the condition is treated by surgically opening
the fused suture. One individual was found with the
marked asymmetry of the skull indicating another
relative common deformity that occurred at birth and
is called torticollis. Nerves supplying the muscles of
the neck may be torn on one side during birth, which
results in partial paralysis and abnormal carriage of
the head in a p o s i tion bent towards a shoulder. This
in time produces asymmetrical growth of the skull
base and face, unless
RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
177
Fig. 5. Skull of an adult with the
right parietal bo n e sh o wi n g
signs of traumatic injury. The wound,
probably inflicted with a sharp
weapon, healed successfull long
before the person’s death. Note
rugosities on the parietal bones that
may be a result of pericranial
inflammation
(Soprintendenza
Archeologica di Pompei, Lab.
5).
Fig. 6a-b. Striation on the shaft of the
tibiae as periosteal reaction to infection
(a). Close- p (b).
Fig. 7. Femur from a person with
congenital hip displacement. Note
severe remodelling of the head and
neck.
178
MACIEJ HENNEBERG AND RENATA J. HENNEBERG
F i g . 8. Skull of a young child. The left coronal
suture between the frontal bone and the left
parietal bone closed prematurely causing
asymmetrical growth of the skull and pressure on the
growing brain (Soprintendenza Archeologica di
Pompei, Lab. 3).
24
HENNEB RG R.J. AND
HENNERERG 1999.
25
AVRAHAMI ET AL.1994.
26
CIARALLO 2000.
27
ORTNER AND PUTSCHAR 1985.
28
BARWICK ET AL. 1997, BARWICK
ET AL., 2000
treated surgically in childhood. Mild congenital anatomical variation of the sacrum and adjacent lowest
lumbar vertebrae consisting of the incomplete closure
of the spinal canal (spina bif d occulta) was quite
common among Pompeians, occurring at about 11%.
It was, however, less common than in modern populations where it exceeds 20%24 Although it seems to be
just a variation in the anatomical structure, it may be
related to lower back pain since spinal nerves are less
well protected than in a completely closed spinal
canal.25
Arthritic diseases of degenerative (age-related)
type were common among Pompeians (tab. 2). The
rheumatoid (infectious) type of arthritis was also
present in the population but was rather rare. Arthritis
frequently affected vertebral columns and occasionally
other joints (figs. 9-12). These, like today, could cause
considerable pain and discomfort which had to be
somehow treated without modern pain killers. The
concoction of plants and animal parts with a substantial
amount of Papaver somniferum, containing opium, was
a partial solution for dealing with pain during surgery
and as a cure for other painful ailments.26
Pompeian were also affected by other ailments
related to aging. We found three cases of Paget's
diseases also known as osteitis deformans.27 In some
people aged 45 years and older, normal processes of
bone renewal and remodelling become irregular. It
results in producing abnormal, thick bone tissue which
alters the normal shape of a skeleton. The disease is still
of unknown origin and produces bone pains and, in
later stages, "ape-like" posture and limitation of
mobility. First of all the disease affects the structure of
bone tissue, thus histological investigation was
necessary to differentiate between the diseases
producing similar thickened bones and to diagnose the
presence of this disorder among Pompeians.28
Neoplastic growth, both benign and malignant, was
also found in Pompeian bones. A number of cases of
small button-like benign bone tumors called osteoma
were found on skulls and long bones. On two femora a
profuse lacework growth of delicate bone spicules indicated the presence of well-advanced malignant tumors
involving muscle and bone tissue: osteosarcoma.
Ancient Pompeians were therefore not free from pain
caused by malignant cancer.
RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
179
Fig. 9. Degenerative arthritis (osteoarthritis)
of vertebrae. Marginal lipping (bony
outgrowth) around the vertebral bodies.
Pitted surface of the vertebral bodies.
Fig. 10. Large osteophytes and remodelling
of all articular surfaces of the cervical
vertebrae due to arthritis. Arthritic damage
of the vertebral bodies.
DENTAL HEALTH
Teeth are very durable and thus are usually
well pre-served in archaeological skeletal
materials. Due to their obvious use for food
mastication, their cosmetic significance, and their
occasional use in economic activities (holding
objects or chewing through leather etc.) teeth are
an important source of information about
individual habits. Once formed, crowns of the teeth
are not remodelled. Thus the structure of the dental
tissues retains information about health conditions of
individu-als during their childhood when teeth were
formed in the gums. Abnormally changed enamel
(hypoplasia) may suggest the presence of an
infectious disease, or lack of nutrients because of a
simple shortage of food, or the presence of a systemic
disease. Linear hypoplasia in a
180
MACIEJ HENNEBERG AND RENATA J. HENNEBERG
Fig. 11. Fusion (ankylosis) of the sacrum and
right hip bone in the sacroiliac joint. Arthritic
remodelling of the fourth and fifth sacral
segments.
Fig. 12. Osteoarthritis in the knee joint.
Distal end of the left femur with marginal
lipping around condyles (bony outgrowth)
and eburnation on the surface of the medial
condyle (shiny patch).
RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPE FROM THE HARD EVIDENCE OF BONES AND TEETH 181
Fig.13. Part of the mandible of a
juvenile with linear enamel hypoplasia
on teeth. Two horizontal lines of
thinner enamel are visible on the
canine and at least one on the
premolar.
Fig. 14. Part of the maxilla with only
one tooth covered by a thick layer of
tartar. Note pitting and remodelling of
the alveolar bone indicating
inflammation of the alveolar process
in periodontitis. Larger holes above
the lost molar, to the right of the
remaining one in the jaw, indicate
periapical abscesses (inflammation
around roots of teeth often due to
severe caries).
form of rings of thinner enamel occurred
commonly among Pompeian (fig. 13). Many
individuals had multiple rings of enamel most
probably related to infectious childhood diseases.
A few cases of non-linear type were also found in
the skeletal sample suggesting the presence of
systemic diseases.
Pompeians were often affected by dental
caries (tables 3, 4). Nearly all individuals had at
least one carious tooth while one third of all teeth
available for observation were affected by caries.
About every tenth tooth was lost during the life of
an individual. Although these lost teeth cannot be
directly studied, it can be assumed that, as in most
recent times, the most common cause of tooth
extraction or natural loss was caries.
Deep caries penetrating to the pulp cavity often
182
MACIEJ HENNEBERG AND RENATA J. HENNEBERG
results in the pulp infection spreading through the canal
in the root to the apex of the root. It causes inflammation of the tissues surrounding the root and results in
formation of abscesses. An abscess produces a cavity in
the bone that often opens by a fistula to the vestibule of
the mouth. About one quarter of all individuals in Pompeii had an abscess in the mouth. Periodontal disease,
an inflammation of gum tissue and the underlying bone,
was also quite frequent and affected about every second
individual. In many instances we have observed layers
of dental calculus (tartar) which were several
millimeters thick (fig. 14).
The entire picture of dental pathologies indicates
lack of dental hygiene, frequent toothache, and rather
prevalent unpleasant mouth odour. It seems that the
only form of dental treatment was the occasional
removal of a carious tooth.
BODY SIZE AS AN INDICATOR OF HEALTH
STATUS
29
HENNEBERG M. ET AL.
1989.
30
KROGMAN AND ISCAN
1986, RUFF ET AL. 1997
Child growth and adult body size are the simplest
indicators of the general living conditions when compared between populations of similar hereditary determinants of body size. Body height can be reconstructed
from the length of skeletal elements, especially the long
bones of the limbs. A number of equations allowing
pre-diction of body height from bone length ha e been
developed. Body weight is reflected in the size of
skeletal elements, though the amount of fat deposited in
the body during adulthood hardly influences the size of
bones. Therefore reconstructions of body weight are
only valid for average individuals and represent a body
of normal composition. On a population level, there is a
strong correspondence between body height and body
weight.29 Thus the simplest but still informative method
of calculating body weight is the use of its relationship
to height. More elaborate methods, taking into account
width of skeletal elements as well as body height, are
also available.30
The formulae allowing the reconstruction of body
height from the length of long bones are sex-specific.
Femora and humeri have characteristics allowing the
determination of sex. In the first instance only these
bones were used to reconstruct the body height of
Pompeians. In order to avoid duplicate representation of
same individuals only right bones were used. This does
not exclude a possibility that the right humerus and the
right femur of the same individual were used, but
ensures that in estimates from the same bone, femur or
humerus, each individual is represented only once. The
total material selected for calculations provided a large
sample of 272 bones. The maximum length of each
femur and humerus was measured to the nearest
millimeter on a portable osteometric board.
For reconstruction of stature we have used two basic
methods: regression equations and proportion of the
length of a given bone to the total body length (height,
stature). In regression equations the measured length of
a bone is multiplied by a constant. Another constant is
then added to the result. Constants were obtained by
various authors who studied samples of bones from
individuals of known stature by means of calculating
parameters of linear regressions. This method, although
based
RECONSTRUCTING MEDICAL KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
on a relatively sophisticated statistical analysis, has a
tendency to overestimate stature of very small individuals
and underestimate stature of very tall ones. This is due to
the fact that correlation between bone length and stature
is not perfect and some scatter of individual points
around the regression line exists. Estimates of individual
statures from regression equations are reasonably good,
but in a sample this method tends to restrict the range of
variation.
The proportion method is very simple. In a sample of
skeletons of individuals of known stature, the length of
bones is measured and then expressed as a fraction of
stature. If, for example, one has determined that the
length of a humerus (H) constitutes on average 19% of
the stature (S), knowing the actual length of an ancient
humerus it is easy to calculate the stature: S=100W19.
This method can be criticized for not taking into account
the possibility that proportions of limb length to stature
can change with total body length. For instance, short
individuals often have relatively short legs and long
trunks. On the other hand, because it does not rely on
imperfect correlations, it does not produce the narrowing
of variation ranges in samples. We have used both
methods and five sets of specific formulae developed for
people of European origin. Exact sources of formulae are
given in table 5.
In large samples of humans the relation between body
height and body weight is reasonably constant. It is
described by the equation W=aexp (bH) where W weight in kg, H - height in cm; a oscillates around 2.0
and b around 0.02.31 Thus it is possible to estimate average body weight of a sample of individuals of known
height. Such an estimate has a largely illustrative value
since, for comparison with other samples and for the
assessment of variability, it suffices to study body height.
In our study of people buried at the ancient Greek cemetery of Pantanello (Metaponto), we used a=2.05 and
b=0.0208.32 These values were derived from statistical
analysis of average adult heights and weights of 52
human populations world-wide.33 The same values were
reapplied here for Pompeii.
The reconstructed statures vary depending on the
method and bone used in their calculations (tab. 5). The
range for Pompeian males is from 163.1 to 169.4 cm, for
females from 151.6 to 155.8 cm. This is mostly a result
of various methods based on different samples. For
purposes of further discussion, keeping in mind the range
of estimates, one can assume male stature to be
183
Table 5. Body height of the inhabitants of ancient Pompeü
reconstructed from the length of right femora and humeri by
means of various methods. Sample sizes: male femora 66,
female femora 100, male humeri 61, female humeri 45.
Results in centimeters.
Method
PEARSON 1899
(regressions)
Bone
femur
Sex Average
Standard
Deviation
M
F
M
F
164.9
152.2
163.1
151.6
4.3
4.3
5.2
3.8
M
F
M
F
166.9
153.0
165.5
153.4
8.5
8.1
9.3
7.2
M
F
M
F
167.3
154.9
168.9
155.8
5.4
5.4
5.6
4.6
DPPERTDIS AND femur
HADDEN 1951
(proportions)
humerus
M
F
M
F
169.4
155.3
168.2
154.8
8.7
8.2
9.5
7.3
TELKKÄ 1950
(regressions)
M
F
M
F
167.2
155.0
166.8
152.5
4.8
3.9
5.1
humerus
HRDLI KA 1939 femur
(proportions)
humerus
TROTTER AND
GLESER 1952,
1977
(regressions)
femur
humerus
femur
humerus
3.7
31
around 166 cm and female stature 154 cm. These results are
nearly identical to those found by Pardini et al. for
Pontecagnano (5th-4th cent. B.C., males 166.3, females
153.9).34 Our range of estimates for Pompeii matches the
range found in most populations of classical antiquity
including Metaponto.35 The results are even similar to those
of modern males from the province of Matera studied by
Cappieri,36 but are slightly above statures found for Central
Italy in the first to the fift h centuries A.D.37 The statures of
male and female Pompeian are significantly shor t er than
those recommended by the World Health Organization as a
modem reference (fig. 15).38
With the reconstructed stature of Pompeian being average
for the ancient inhabitants of Italy, it is not surprising that
reconstructed average weight is of the same nature: males 66
kg (61-70 kg), females 50 kg (48-52 kg). It is wort h noting
that body weight of 65 kg is taken as a "standard" weight for
males in many physiological
HENNEBERG M. ET
AL. 1989.
32
HENNEBERG M.
AND HENNEBERG
1990, HENNEBERG
M . ET AL. 1992,
HENNEBERG M . AND
HENNEBERG
1998.
33
HENNEBERG M. ET
AL. 1989.
34
PARDINI ET AL. 1982.
35
HENNEBERG .
AND HENNEBERG 1990,
HENNEBERG M . AND
HENNEBERG 1998,
HENNEBERG M . ET AL.
1992.
36
CAPPIERI 1978.
37
RUBINI 1994.
38
For NCHS statistics,
see HAMILL ET Al.
1977.
1 8 4 MACIEJ RE NNE B E RG AND RENATA J . RE NNEB E R G
F i g . 15. Comparison of statures.
and nutritional considerations. It has been accepted by
the Food and Agriculture Organization of the United
Nations (FAO) as a model body size in temperate
climates.
Standard deviations of stature reconstructed by
means of regression formulae are appreciably smaller
than those obtained from simple proportions. This has
been expected on grounds of general statistical
regularities. It is worth noting that supposedly unbiased
standard deviations for stature reconstructed from
proportions are similar to or slightly greater than those
typically found in various living populations, where they
oscillate around 6 to 7 centimeters.39
Further studies may include measurements and
descriptions of body casts. The casts preserve large
amounts of anatomical detail, including that of the
surface of the brain and meningeal blood vessels (fig.
16).
CONCLUSIONS
39
HENNEBERG M . AND
V A N D E N B E R G 1990.
It may be concluded that the skeletal sample excavated from the ruins of Pompeii is representative for the
inhabitants of this Roman city. Sex ratio is approximately 1:1, population structure by age similar to that of
other ancient and pre-industrial populations.
Mortality was high mostly due to infectious
diseases while the services of skilled surgeons,
though available, as manifested by well-set
fractures and well-healed wounds, were accessible
only to some individuals. The ability of surgeons
to manipulate parts of the human body in a
mechanical way was not decisive in reducing
mortality.
There is an indication of the presence of a
chronic systemic infection in Pompeii, possibly a
treponematosis, though further studies are needed
to confirm this observation.
In the skeletal material from Pompeii, ranges
of variability of body size and the degree of sexual
dimorphism are typical for any human population.
The average reconstructed heights and weights
indicate that the body size of ancient Pompeian
was similar to that of inhabitants of other ancient
Greek and Roman cities. It seems that the
population of Pompeii has been physically similar
to that of many other cities of the Roman Empire.
Physical growth of boys and girls in Pompeii took
place in conditions typical for Italy from classical
antiquity until the first half of the twentieth century.
These were far below those observed in modern
First World societies and as indicated by statures
clearly shorter than the reference recommended by
the World Health Organization. Good
RECONSTRUCTING MEDICAL.KNOWLEDGE IN ANCIENT POMPEII FROM THE HARD EVIDENCE OF BONES AND TEETH
185
Fig 16. Endocast of an adult brain. Well
visible are the two hemispheres with sulci
and gyri of the cerebral cortex and branches
of meningeal arteries supplying blood to the
brain. The endocast of the brain was made
accidentally when liquid plaster of Paris was
poured into the cavity left by a human body in
pyroclastic material.
nutrition was available to Pompeians as shown
by archaeological and historical sources, thus it
seems that disease was the major cause of poor
growth of children.
In contrast to the beauty of architecture and art
that the people of ancient Roman times created, the
individual life was short and full of pain.
Acknowledgements
The authors wish to thank the Soprintendenza
Archeologica di Pompei for the invitation to join the
team of researchers associated with its Laboratorio di
Richerche Applicate. In particular we are grateful to
Professor Pietro G. Guzzo, Superintendent of Pompeii,
Dr. Annamaria Ciarallo, Director of the Laboratorio,
and Professor Baldassare Conticello, former
Superintendent of Pompeii, for the per-mission to study
the human skeletal remains in their care.
During
our
collaboration
with
the
Soprintendenza Archeologica di Pompei, the
financial support of our studies was provided by the
Australian Research Council and the Wood Jones
Bequest at the University of Adelaide (Australia), the
Foundation for Research Development of South
Africa, the University of the Witwatersrand, Johannesburg (South Africa).
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