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A Cut Above: Amputation, Disease and Digital Radiographic Analysis of Long Bones from the Worcester Royal Infirmary, England

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Excavations at the former Worcester Royal Infirmary revealed a series of pits in its grounds containing 1828 fragments of human bone. The find was unexpected. No formal burial ground was ever established at the hospital during its history. The human
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  A Cut Above: .  Amputation, Disease and Digital Radiographic Analysis of Long Bones from the Worcester Royal Infirmary, England. Gaynor Western, Ossafreelance, info@ossafreelance.co.uk Jelena Bekvalac, Centre for Human Bioarchaeology, Museum of London, jbekvalac@museumoflondon.org.uk Mark Farmer, Reveal Imaging Ltd., mpfarmer@gmail.com   Radiography by Mark Farmer, Reveal Imaging Ltd. WRI [63]: Thin Periostitis. Left Tibia, Adult. M-L View A-P View Pseudofracture WRI [552]: Solid Cloaking. Left Radius, Adult. Permeative A-P View   A-P View This element has macroscopically observable striated & porotic lamellar bone periostitis. Radiographically the periostitis is classified as solid  –  thin. Note also transverse radio-opaque lines representing possible pseudofractures (incomplete stress fractures). Macroscopically, this radius has a swollen and irregular appearance with complete obliteration of the medulla by endosteal bone formation. Radiographically the bone is opaque with poor definition of the cortices. An area of solid  –  cloaking periostitis is seen. P-M Damage WRI [804]: Interrupted Amorphous. Left Femur, Adult. Radiographically, (1) interrupted amorphous, (2) solid undulating   and (3) solid straight   periostitis is visible. The moth eaten appearance indicates medullary involvement. A cloaca indicated by a radiolucent circular geographic lesion is present. Pyogenic septic arthritis. Moth Eaten Geographic   WRI [556]: Interrupted Laminated. Right Radius, Adult. Macroscopically, mixed lamellar and woven bone can be seen proximally but this is thin and cannot be seen radiographically. Distally there is interrupted laminated periostitis, indicating an aggressive or malignant bone lesion. Osteopenia and a healed Colles fracture are also present. A-P View A-P View 1 2 3   A-P View Osteopenia Healed Colles Fracture Woven and lamellar periostitis Radiographic recording methodology is based on the identification of bone structure High density Low density Bone formation Bone loss (osteosclerosis) (osteopenia) (Similar principles to palaeopathology i.e. osteolytic v osteoblastic lesions but refers to the whole content of the bone not just its external surface:) Record the location and extent of bone loss and formation prior to interpretation Standardised terminology already exists in radiology   No   %   Transected Elements (Total)   76   Macroscopic and radiographic changes   27   35.5   Macroscopic change only   5   6.5   Radiographic changes only   8   10.5   No macroscopic pathology or radiographic changes   36   47.4   Bone change can be: •  Permeative (most aggressive), •  Moth Eaten (sub-acute and chronic) •  Geographic (benign) Recording the type of periostitis aids identification of benign and aggressive conditions: distinguish between solid & interrupted types RADIOPAQUE RADIOLUCENT Excavations at the former Worcester Royal Infirmary revealed a series of pits in its grounds containing 1828 fragments of human bone. The find was unexpected. No formal burial ground was ever established at the hospital during its history. The human remains are dated to the late Georgian and early Victorian period (1775-1850 AD). So what did these remains represent? Osteological analysis of the remains revealed that 236 elements had been artificially modified. Modification consisted of transection, bisection, trepanation, craniotomy and defleshing marks. Many of the bone fragments exhibited gross pathological changes from severe infection and inflammation. Some of the modified bones exhibited no obvious signs of pathology. However, when we are assessing bone macroscopically, we are only looking at the outer surface, a tiny percentage of the total bone present. Direct Digital Radiography (DDR) allows us to visualise the internal content of bone and record lesions to modern clinical standards. We used DDR to investigate the motive behind the transection of the long bones in the assemblage. Did the assemblage consist of diseased limbs representing surgical waste or was the absence of pathology evidence of other practices, such as surgical training or anatomical dissection? Amputation was a life saving operation prior to the introduction of anaesthesia from the 1840 ’s . Infection or trauma to a limb could place individuals in mortal danger. In this pre-antibiotic era, amputation was not an operation without high risk but was a necessary means to an end in cases of either life or limb. Liston’s   Elements of Surgery   (1842) states that amputation was carried out in the following cases: •  Severe Fractures: with extensive soft tissue damage and traumatic gangrene •  Joint diseases: tumours, caries and abscesses involving the joints •  Bone Diseases: tumours, aneurismal tumours, spina ventosa, malignancies without soft tissue involvement, tumours and ulcers of soft parts •  Inflammation: chronic conditions with exfoliation and suppuration •  Mortification: chronic constitutional, exposure or hospital gangrene •  Iatrogenic: Badly formed stumps Limbs were also removed post-mortem as part of surgical training and as part of anatomical dissection practice, where body parts were shared between students. Additionally, preservation techniques were limited so putrefying remains were periodically removed from the dissection room while other body parts were retained as anatomical preparations for teaching and display in museums. Using DDR, lesions were detected in an extra 10.5% of the 76 transected long bones examined. In the total sample of elements with medullary changes (N=13), 38.5% were permeative (aggressive), 46.2% were moth eaten (chronic) and 15.4% were geographic (benign). Amputation was consistently undertaken for more severe conditions. Where periostitis was co-occurring, all interrupted laminated and amorphous types were associated with permeative and moth eaten changes (N=4). Solid periostitis occurred with all types of medullary changes but was more frequently found with moth eaten and geographic types (n=13, 86.7%). DDR analysis confirmed that 47.4% of transected elements had no evidence of pathology. A significantly greater number of diseased fragments were distal portions, suggesting amputation. The transected elements without pathology were more equal in proximal and distal portions, indicating dissection or post-mortem dismembering. Four cases of aggressive or acute conditions were present in the transected bone sample that exhibited no macroscopic change. These may represent acute/sub-acute osteomyelitis or malignant neoplasms. Lesions only detected by radiography were more common in upper elements of limbs (i.e. humerus and femur), possibly reflecting haematogenous spread of infection from more distal sites. Ascending infections are frequent complications of osteomyelitis and gangrene leading to the requirement for major amputation. Amputation for acute sloughing gangrene was regularly undertaken at the Worcester hospital by the surgeon Henry Carden between 1838 and 1864. Image from Manual of Surgery (1921) by Thomson and Miles The use of DDR allows a comprehensive assessment of the pathology present in skeletal assemblages to be undertaken. Though not without its limitations, it is difficult to draw sound conclusions about the prevalence rates of disease without radiographic examination of the internal structure of bone. DDR can detect acute and aggressive conditions that cannot be identified on the basis of macroscopic analysis alone. DDR analysis has confirmed the presence or absence of pathology in transected long bone elements at the Worcester Royal Infirmary that otherwise showed no evidence of disease and were ambiguous as to the motive for their artificial modification. This has allowed us to calculate more accurate prevalence rates and make a fair comparison to historical records of diseases and treatment. Overall, we can now demonstrate that amputation was most frequently carried out for grave pathological conditions, as the contemporary records suggest. Some cases of otherwise unobservable ascending infection may also have been detected. However, the combination of DDR data and the sample composition suggest that long bone transection also occurred for the purposes of anatomical dissection and post-mortem dismemberment.   S  o  m  e  E  x  a  m  p  l  e  s  D  D  R  M  e  t  h  o  d  o  l  o  g  y A-P View After Burgener, Kormana and Pudas (2006) Bone and Joint Disorders.   A  m  p  u  t  a  t  i  o  n   i  n   E  a  r  l  y  M  e  d  i  c  i  n  e  R  e  s  u  l  t  s  C  o  n  c  l  u  s  i  o  n  BABAO Funded Research
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