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The term 'joint disease' encompasses a large number of conditions with different causes, all of which affect the articular joints. Factors influencing joint disease include physical activity, occupation, workload and advancing age, which manifest as degenerative joint disease and osteoarthritis. Alternatively, joint changes may have inflammatory causes in the spondyloarthropathies, such as sceptic or rheumatoid arthritis, or may be the result of autoimmune joint diseases, such as DISH and ankylosing spondylitis. Gouty arthritis, a metabolic joint disease, affects the bones of the feet. All of these conditions affect the articular joints in different ways, and it is the type of lesion, together with the distribution of skeletal manifestations, which determines the diagnosis.
Degenerative joint disease (DJD) is commonly observed in skeletons from archaeological contexts. DJD is characterised by both bone formation (osteophytes) and resorption (porosity, subchondral cysts) at and around the articular surfaces of joints (Plate 10, right). The prevalence of DJD can be influenced by age, sex, functional stress, genes and endocrine agents (Jurmain 1980, 143) and can cause great discomfort and disability (Rogers 2000).
The distribution and prevalence of joint involvement tends to be population-specific, with greater variation in archaeological populations as compared with modern clinical patients. The pattern of joint involvement may suggest the cause. Asymmetrical, or severe DJD is often the result of functional stress, with lesions on the joint surface taking the form of porosity; the elbow and knee tend to be particularly sensitive to such stress. Age-related DJD, on the other hand, is more likely to be symmetrical, with osteophyte formation (bony outgrowths) at the joint margins. Osteophytes are a response to joint failure and an attempt to repair the joint through surrounding bone formation (Rogers 2000); most particularly, DJD of the hip and shoulder tends to be age-related (Jurmain 1991, 249).
Table 28 below illustrates that DJD increased progressively with age in the Fishergate House population, and that it was most prevalent in old middle adults, and particularly in mature adults of both sexes. DJD was found to increase dramatically in males between the young (30%) and old middle adults (100%). This may imply that male DJD was largely age-related, whereas female DJD was more activity-related, although the effects of this would also have increased with age. Osteophytes were the most common manifestation of joint disease, followed by porosity, and only a few subchondral cysts.
| Age group | Male | Female | Undetermined | Total | ||||
|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | |
| Young adult | 2/7 | 29 | 0/5 | 40 | 0/3 | 0 | 2/15 | 13 |
| Young middle adult | 5/14 | 29 | 7/10 | 70 | 0/0 | 0 | 12/24 | 50 |
| Old middle adult | 14/14 | 100 | 13/15 | 87 | 1/2 | 50 | 28/31 | 90 |
| Mature adult | 16/16 | 100 | 22/23 | 96 | 0/0 | 0 | 38/39 | 97 |
| Adult | 1/6 | 17 | 0/0 | 0 | 10/16 | 38 | 11/22 | 32 |
| Total | 38/57 | 67 | 42/53 | 79 | 11/21 | 33 | 87/131 | 66 |
A greater proportion of females (79%) were affected by DJD than males (67%), although a greater number of male bones showed evidence for the condition (Figure 17). A total of 66% of the adult population from Fishergate House exhibited evidence for DJD in one or several joints (36% of the total population). Because recording methods for DJD are not consistent, comparisons with other populations were not always possible. However, at Hull Magistrate's Court, 54.5% of adults had some evidence for DJD (48% of the population), with 57.5% of males and 59% of females affected.
Figure 17
The greatest prevalence of DJD was noted in the shoulders in both sexes, particularly in the lateral clavicle (Table 29). Additionally, the sternal joints of the clavicle showed a high incidence of DJD. DJD was also common in both hip joints, in the highly movable femur-pelvis joint (acetabulum) as well as the rigid joint between the hip and sacrum (auricular surface), although prevalence rates differed considerably between the sexes.
| Joint | Male | Female | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Right | Left | Right | Left | |||||||
| No. | % | No. | % | No. | % | No. | % | No. | % | |
| Shoulder acromion | 13/33 | 39 | 10/36 | 28 | 7/28 | 25 | 6/29 | 21 | 36/126 | 26 |
| Shoulder lateral clavicle | 24/36 | 67 | 19/34 | 56 | 11/31 | 35 | 12/27 | 44 | 66/128 | 52 |
| Shoulder glenoid | 9/35 | 26 | 11/39 | 28 | 3/35 | 9 | 3/35 | 9 | 26/144 | 18 |
| Shoulder humerus | 5/38 | 13 | 4/36 | 11 | 5/33 | 15 | 2/34 | 6 | 16/141 | 11 |
| Manubrium S/C | 19/41 | 46 | 20/38 | 53 | 6/29 | 21 | 6/33 | 18 | 51/141 | 36 |
| Elbow humerus | 2/42 | 5 | 2/41 | 5 | 3/38 | 8 | 2/41 | 5 | 9/162 | 6 |
| Elbow radius | 1/41 | 2 | 1/37 | 2 | 0/36 | 0 | 2/35 | 6 | 4/149 | 3 |
| Elbow ulna | 3/39 | 8 | 4/39 | 10 | 0/39 | 0 | 0/39 | 0 | 7/156 | 4 |
| Wrist radius | 1/33 | 3 | 2/35 | 6 | 0/30 | 0 | 0/34 | 0 | 3/132 | 2 |
| Wrist ulna | 3/39 | 8 | 2/33 | 6 | 1/32 | 3 | 1/34 | 3 | 7/138 | 5 |
| Wrist carpals | 5/44 | 11 | 6/37 | 16 | 1/39 | 3 | 0/36 | 0 | 12/156 | 8 |
| Hand | 8/48 | 17 | 8/44 | 18 | 6/43 | 14 | 6/41 | 15 | 28176 | 16 |
| Hip auricular | 27/45 | 60 | 24/43 | 56 | 23/44 | 52 | 26/45 | 58 | 100/177 | 56 |
| Hip acetabulum | 10/47 | 21 | 10/43 | 23 | 8/43 | 19 | 12/43 | 28 | 40/176 | 23 |
| Hip femur | 5/45 | 11 | 2/41 | 5 | 6/40 | 15 | 6/39 | 15 | 19/165 | 12 |
| Knee femur | 1/45 | 2 | 3/45 | 7 | 1/36 | 3 | 1/35 | 3 | 6/161 | 4 |
| Knee patella | 1/34 | 3 | 1/33 | 3 | 4/29 | 14 | 3/22 | 14 | 9/118 | 8 |
| Knee tibia | 2/43 | 5 | 2/44 | 5 | 2/35 | 6 | 1/36 | 3 | 7.158 | 4 |
| Ankle tibia | 0/41 | 0 | 0/41 | 0 | 0/34 | 0 | 0/33 | 0 | 0/149 | 0 |
| Ankle tarsals | 1/40 | 3 | 1/39 | 3 | 0/35 | 0 | 2/35 | 6 | 4/149 | 3 |
| Foot | 4/35 | 11 | 2/37 | 5 | 2/33 | 6 | 2/31 | 6 | 7/136 | 7 |
The prevalence rate of DJD in each joint was usually greater in males than in females (see Figure 17). Female knees and hips were more likely to be affected, whereas males had a greater prevalence of DJD in the elbows, shoulders, wrists and hands, suggesting that the different distribution of lesions in males and females may have been associated with different activities.
When examining the prevalence rate of DJD for the right and left sides of the body, it was noted that the male left shoulder joints were considerably less affected by DJD than the right side. This was not the case in females, where different parts and sides of the shoulder joint were affected to a different extent. The male left wrists showed less evidence for DJD as compared with the right wrist. This may point to activity-related DJD in male upper limbs.
The relative symmetry of DJD lesions, as well as the expression of lesions in the form of osteophytes and the older age of onset, suggests that age is a major factor contributing to the development of DJD. However, the fact that over one third of the population suffered from DJD before the age of thirty-five, and that the distribution of lesions is sex-specific, suggests that development must be partly attributed to activity-related wear, exacerbated subsequently with age.
Primary osteoarthritis is a multifactoral disorder, affected by sex, age, genes, metabolism, hormones, nutrition, bone density, infection, vascular deficiencies, obesity, mechanical stress and physical activity (Larsen 1997, 239). It is a degenerative joint disease characterised by the deterioration of the joint cartilage, leading to exposure of the underlying bony joint surface. This may cause porosity, subchondral cyst formation or osteophyte formation on and around the joints. At least two of these manifestations need to be present for osteoarthritis to be diagnosed (Rogers and Waldron 1995). The resulting bone to bone contact can result in polishing of the joint surface, termed eburnation (the bone takes on a shiny, ivory-like appearance), which is the most significant expression of osteoarthritis (Plate 11, right). Notably, studies of modern patients have found that while some individuals with no bone changes may be crippled, others may have severe joint changes without any disabling affects (Cockburn et al 1979).
Although specific patterns of joint involvement of osteoarthritis are found in different populations, an association between osteoarthritis and functional stress cannot often be established (Jurmain 1991, 248). Jurmain ibid argues, therefore, that not only is the type of activity carried out important, but also the duration of stress on the joints ibid, 249). It is possible that a greater prevalence in one sex may not suggest greater functional stress in this group, but rather, may indicate an earlier age in the adoption of an activity (Larsen 1997, 178). Osteoarthritis is thus thought most likely to affect joints which are placed under repetitive stress for a number of years.
Individuals' activities are rarely documented for archaeological populations, limiting functional interpretation on the basis of DJD and osteoarthritis. However, Waldron and Cox (1989) carried out a study of osteoarthritis in individuals of known age and occupation from the post-medieval cemetery at Spitalfields, London. They found that the weavers in this population had no occupation-specific arthritis. The most significant factor relating to osteoarthritis in this population was age, with a mean age of 71.6 years in those individuals found to have osteoarthritic lesions. The lack of osteoarthritis in such a group supports Bridges' (1991) theory, which suggests that osteoarthritis is secondary to trauma or high intensity but infrequent activities, rather than to constant stress.
Only 19% of adults (10% of the population), all of whom were older than thirty-six years, suffered from osteoarthritis in one or more extraspinal joints (Table 30; see Figure 17). The condition affected slightly more males (23%) than females (19%). This compares reasonably well with other medieval cemeteries; at Hull Magistrate's Court, for example, 18% of the adults (15% of the population) were affected by the condition, although the prevalence in both males and females with osteoarthritis was 19%.
| Age group | Male | Female | Undetermined | Total | ||||
|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | |
| Young Adult | 0/7 | 0 | 0/5 | 0 | 0/3 | 0 | 0/15 | 0 |
| Young Middle Adult | 0/14 | 0 | 0/10 | 0 | 0/0 | 0 | 0/24 | 0 |
| Old Middle Adult | 6/14 | 43 | 1/15 | 7 | 0/2 | 0 | 7/31 | 23 |
| Mature Adult | 7/16 | 44 | 9/23 | 39 | 0/0 | 0 | 16/39 | 41 |
| Adult | 0/6 | 17 | 0/0 | 0 | 1/16 | 6 | 1/22 | 5 |
| Total | 13/57 | 23 | 10 | 19 | 1 | 5 | 25/131 | 19 |
The same proportion of male old middle adults and mature adults was affected by osteoarthritis, whereas the condition increased dramatically with age in the female group. It was observed that most individuals suffered from osteoarthritis in one extraspinal joint only, suggesting that it is possible that the condition was sometimes trauma-related in the Fishergate House population.
Skeletal manifestations indicative of extraspinal osteoarthritis were only observed in a small number of joints (Table 31), particularly in the shoulders of both sexes, and in the hands of males. Additionally, the wrist, hip, knee and foot could be affected in both sexes, and the elbow in male skeletons exclusively. Unlike in other historic and modern populations, overall prevalence rates for osteoarthritis were highest in the shoulders, followed by hands and feet, rather than in the knees and hips (Roberts and Manchester 1995, 114). The high incidence of osteoarthritis in the shoulder corresponded with the high prevalence of DJD in the same joint. However, hand and foot osteoarthritis was much less prevalent than DJD in these elements, suggesting that different factors influenced the aetiology of the two types of joint disease.
| Joint | Male | Female | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Right | Left | Right | Left | |||||||
| No. | % | No. | % | No. | % | No. | % | No. | % | |
| Shoulder acromion | 2/33 | 6 | 3/36 | 8 | 7/28 | 25 | 6/29 | 21 | 18/126 | 14 |
| Shoulder lateral clavicle | 4/36 | 11 | 4/34 | 3 | 0/31 | 0 | 0/27 | 0 | 8/128 | 6 |
| Shoulder glenoid | 1/35 | 3 | 0/39 | 0 | 0/35 | 0 | 0/35 | 0 | 1/144 | 1 |
| Shoulder humerus | 1/42 | 2 | 2/41 | 5 | 3/38 | 8 | 2/41 | 5 | 8/162 | 5 |
| Sterno-clavicular | 2/41 | 5 | 1/38 | 3 | 0/29 | 0 | 0/33 | 0 | 3/141 | 2 |
| Elbow humerus | 1/42 | 2 | 1/41 | 1 | 0/38 | 0 | 0/41 | 0 | 1/162 | 1 |
| Elbow radius | 1/41 | 2 | 1/37 | 6 | 0/36 | 0 | 0/35 | 0 | 2/149 | 1 |
| Elbow ulna | 0/39 | 0 | 0/39 | 0 | 0/39 | 0 | 0/39 | 0 | 0/39 | 0 |
| Wrist radius | 2/33 | 6 | 2/35 | 6 | 0/30 | 0 | 0/34 | 0 | 4/132 | 3 |
| Wrist ulna | 0/32 | 0 | 0/33 | 0 | 0/32 | 0 | 0/34 | 0 | 0/131 | 0 |
| Wrist carpals | 1/44 | 2 | 0/37 | 0 | 1/39 | 1 | 2/36 | 6 | 4/156 | 3 |
| Hand | 5/48 | 10 | 5/44 | 13 | 2/43 | 5 | 1/41 | 2 | 13/176 | 7 |
| Hip auricular | 0/45 | 0 | 0/43 | 0 | 1/44 | 2 | 1/45 | 2 | 2/177 | 1 |
| Hip acetabulum | 0/47 | 0 | 2/43 | 5 | 1/43 | 2 | 0/43 | 0 | 3/176 | 2 |
| Hip femur | 0/45 | 0 | 1/41 | 1 | 1/40 | 3 | 0/39 | 0 | 2/165 | 1 |
| Knee femur | 0/45 | 0 | 0/45 | 0 | 2/36 | 6 | 1/35 | 3 | 3/161 | 2 |
| Knee patella | 0/34 | 0 | 0/33 | 0 | 0/29 | 0 | 0/22 | 0 | 0/118 | 0 |
| Knee tibia | 0/43 | 0 | 0/44 | 0 | 0/35 | 0 | 0/36 | 0 | 0/158 | 0 |
| Ankle tibia | 0/41 | 0 | 0/41 | 0 | 0/34 | 0 | 0/34 | 0 | 0/150 | 0 |
| Ankle tarsals | 0/40 | 0 | 0/39 | 0 | 0/35 | 0 | 0/35 | 0 | 0/149 | 0 |
| Foot | 0/35 | 0 | 1/37 | 3 | 3/33 | 9 | 3/31 | 10 | 7/136 | 5 |
The prevalence of both DJD and osteoarthritis was much greater in males in the right and left elbows, and it is thought that the combination of these two conditions at this joint may be activity-related. Secondary arthritis can appear in joints which have been damaged through trauma, and have assumed an abnormal position. An example from the Fishergate population includes an old middle adult male (C1560), who suffered from an oblique fracture of a right carpal (scaphoid) which had not united and had caused differential wear on the joints, leading to secondary osteoarthritis. According to Roberts and Manchester (1995, 114), osteoarthritis of the shoulder is also frequently secondary to trauma, but only one case of secondary shoulder osteoarthritis was noted in this population. A mature adult female (C1115), suffered from severe trauma to the left shoulder joint, probably caused by a bladed instrument. Parts of the joint had been lost following the injury, causing the formation of a secondary joint, and secondary osteoarthritis formation on the new joint surfaces.
Most joints affected by osteoarthritis showed complete failure of the cartilage with bone to bone contact in the form of eburnation of the joint surface, and some porosity and osteophyte formation. A mature adult male (C1051) suffered from severe osteoarthritis of the right shoulder, both elbows, the right wrist, right and left hand. The left hip was considerably enlarged (Plate 12, right), with osteoarthritis and distortion of the joint surface, causing such severe restriction of movement at the hip that this individual was buried with the knee at a right-angle. This man also suffered from severe osteo arthritis and fusion of the spine, as well as fourteen rib fractures and inflammatory lesions at the lower limbs. His condition was by far the most severe case of osteoarthritis in this population.
Spinal joint disease is very common in human populations, because of the stress exerted on the spine as a result of bipedalism. The intervertebral discs are the 'shock absorbers' of the spine, but these can degenerate as a result of gradual desiccation, which then causes transmission of the stress from the vertebral discs to the articular facets and ligaments (Hirsh 1983, 123). Spinal osteophytes form in response (Roberts and Manchester 1995, 106), with the aim of providing support and in an attempt to repair the joint (Plate 13, right). Increasing stress or activity can, therefore, lead to increased size and prevalence of osteophytes ibid.
Each vertebral body and vertebral articular facet was analysed for evidence of joint disease, and then summarised with the aim of calculating prevalence rates and producing comparative results. Only the presence of pathology was used in the calculations, and not its severity. All four facets of a vertebra were treated as one in the calculation, as well as the superior and inferior body surfaces. Additionally, both porosity and osteophyte formation were amalgamated for prevalence calculation of DJD.
Both Table 32 and Figure 18 illustrate that degenerative joint disease was more prevalent in the vertebral bodies compared with the vertebral articular facets, with females suffering from a greater prevalence of DJD than males. Vertebral body DJD increased considerably towards the lower end of the spine, with the greatest prevalence in the lumbar vertebrae, particularly in females. This suggests considerable strain on the lower half of the spine and is thought to be the result of heavy manual work. This finding corresponds with the prevalence rate of Schmorl's nodes in the lower spine (discussed below).
Figure 18
| Spinal pathology | Part of spine | Male | Female | Total | |||
|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | ||
| Body DJD | cervical | 90/263 | 34 | 90/232 | 39 | 180/495 | 36 |
| thoracic | 237/458 | 52 | 267/467 | 57 | 504/925 | 54 | |
| lumbar | 127/207 | 49 | 151/209 | 72 | 278/416 | 67 | |
| Body fusion | cervical | 12/263 | 5 | 0/232 | 0 | 12/495 | 2 |
| thoracic | 9/458 | 2 | 8/467 | 2 | 17/925 | 2 | |
| lumbar | 5/207 | 2 | 0/209 | 0 | 5/416 | 1 | |
| Facet DJD | cervical | 23/257 | 9 | 18/202 | 9 | 41/459 | 9 |
| thoracic | 38/387 | 10 | 33/379 | 12 | 71/766 | 9 | |
| lumbar | 13/181 | 7 | 14/186 | 8 | 27/367 | 7 | |
| Facet OA | cervical | 48/257 | 19 | 19/202 | 9 | 67/459 | 14 |
| thoracic | 29/387 | 7 | 15/379 | 4 | 44/766 | 5 | |
| lumbar | 13/181 | 7 | 6/186 | 3 | 19/367 | 5 | |
| Facet fusion | cervical | 8/257 | 3 | 0/202 | 0 | 8/459 | 2 |
| thoracic | 5/387 | 1 | 2/379 | 0.5 | 7/766 | 1 | |
| lumbar | 3/181 | 2 | 0/186 | 0 | 3/367 | 1 | |
| Schmorl's nodes | thoracic | 138/458 | 30 | 107/467 | 23 | 245/925 | 26 |
| lumbar | 58/207 | 28 | 68/209 | 33 | 126/416 | 30 | |
Prevalence rates of spinal DJD increased dramatically with age: only 8% of young adults were affected (1 individual), but the incidence of DJD increased drastically to 78% in the young middle adults with a peak of 97% in the old middle adult and mature adult groups. Eighty-three percent of female spines and 84% of male spines showed evidence for DJD in one or more vertebrae.
Spinal DJD is frequently seen in association with Schmorl's nodes (lesions caused by herniation of the vertebral discs) and it is thought that Schmorl's nodes predispose individual to, and cause an earlier onset of, DJD (Rogers 2000; Hilton et al 1976). It is proposed that the high prevalence of Schmorl's nodes in young adults at Fishergate (present in 62% of young adults with spines) predisposed this population to the development of spinal DJD. The majority of Schmorl's node lesions were associated with DJD in the middle adult and mature adult groups, which further substantiates this theory.
In cases of severe osteophyte formation around the vertebral joints, osteophytes from adjacent vertebrae may fuse (Plate 14, right). Fusion can affect the vertebral bodies or articular facets, or the whole vertebra. It was noted that the prevalence in males was much higher than in females. Significantly, the lumbar and cervical vertebrae were more severely affected in males, whereas only thoracic vertebrae had fused in females. A variety of causes are thought to have been responsible for the vertebral fusion, including DISH (discussed below), causing considerable osteophyte formation on the right side of the spine, which may take a candle wax-like appearance and eventually leads to spinal fusion. Three individuals were thought to suffer from spinal fusion as a result of DISH (C1139, C1228 and C1579). One young middle adult female (C1251) may have suffered from fused vertebrae as a result of a congenital anomaly. Trauma with secondary bone formation was thought to be the cause of vertebral fusion in two males, an old middle adult (C1147) and a young middle adult (C1228). The remaining four individuals were thought to suffer from spinal fusion as a result of osteophyte formation caused by degenerative joint disease.
Spinal osteoarthritis was identified in those cases where eburnation could be observed on the articular surface of the vertebral facet joints. In both males and females, the cervical vertebrae were more severely affected than the thoracic or lumbar parts of the spine (see Figure 18). Cervical osteoarthritis can cause severe pain in the neck, arms and shoulders (Hirsh 1983). The prevalence of osteoarthritis increased with age; no young adults were affected, but 13% of young middle adults, 33% of old middle adults and 51% of mature adults suffered from spinal osteoarthritis.
Spinal osteoarthritis was much more common in males, particularly in the cervical vertebrae (41% of male spines and 24.5% of female spines affected). This contrasts markedly with the almost equal prevalence of DJD in male and female spines.
Schmorl's nodes are indentations in the upper and lower surfaces of the vertebral bodies, which tend to form in the centre of the vertebral body surface (Plate 15, right), most commonly in the lower thoracic vertebrae (Hilton et al 1976). Schmorl's nodes can result from herniation of the intervertebral discs, with subsequent pressure exertion of the contents of the disc onto the vertebral body surface (Rogers 2000). When the disc contents enter the vertebral body, necrosis (death) of the surrounding tissue may result. Herniation of the discs only occurs if sufficient axial compressive forces are causing pressure on the central portion. Physical stress on the spine from continual heavy loading, such as frequent lifting or carrying of heavy loads, is thought to contribute to disc herniation. Schmorl's nodes are thought to develop during late adolescence and early adulthood while the vertebral discs are still elastic (Hilton et al 1976).
At Fishergate House, the percentage of individuals with spines affected by Schmorl's nodes was high (67% of males and 54% of females affected). At St Andrew's, the prevalence was only slightly lower, with 62% of male spines and 42% of female spines affected.
As in other populations, the frequency of Schmorl's nodes was not found to increase with age. Although none of the adolescents from Fishergate House suffered from Schmorl's nodes, 40% of young adult females and 100% of young adult males were found to suffer from the lesions (Table 33). Throughout all age groups but one, fewer females suffered from Schmorl's nodes than males. However, in the young middle adult age group, 60% of females had the lesions, in contrast to only 54% of males. The fact that all young males in this population had evidence for Schmorl's nodes suggests that those men who were subject to severe physical stress were most likely to die during early adulthood. Females who had suffered the most severe physical stress expressed as spinal lesions were most likely to die during middle adulthood.
| Age group | Males | Females | Total (including undetermined adults) | |||
|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | |
| Young Adults | 5/5 | 100 | 2/5 | 40 | 8/13 | 62 |
| Young Middle Adults | 7/13 | 54 | 6/10 | 60 | 13/23 | 56 |
| Old Middle Adults | 9/12 | 75 | 8/13 | 62 | 18/27 | 67 |
| Mature Adults | 10/16 | 63 | 11/22 | 50 | 21/38 | 55 |
| Total | 31/46 | 67 | 27/50 | 54 | 60/101 | 59 |
Schmorl's nodes were found exclusively in the thoracic and lumbar vertebrae, as is usually the case. In males, the prevalence of the lesions increased steeply from the fourth thoracic vertebra downwards, with the highest prevalence in the seventh thoracic vertebra, followed by a gradual decline towards the base of the spine (Figure 19). In females, on the other hand, prevalence rates were relatively uniform from the seventh thoracic to the third lumbar vertebra. Thus, males suffered from a greater prevalence of Schmorl's nodes in the thoracic spine than females (30%:23%), whereas the opposite was true for lumbar nodes (28%:33%). Overall, the prevalence of Schmorl's nodes in the lumbar vertebrae was slightly greater than that in the thoracic spine (Table 33). Lesions were graded from slight to severe, depending on their depth and dimensions. Most individuals were found to suffer from less severe Schmorl's nodes in the upper thoracic and lower lumbar vertebrae, with increasing severity towards the base of the spine, mirroring the distribution of the lesions.
Figure 19
At Hull Magistrate's Court, both male and female lesions were most prevalent between the seventh and twelfth thoracic vertebrae (Holst et al, forthcoming). However, it was found that males suffered from almost twice as many Schmorl's nodes as females (25%:14% of thoracic vertebrae; 16%:8% of lumbar vertebrae), suggesting a clear distinction in axial loading between the sexes ibid, which could not be observed at Fishergate House.
The relative similarity in frequencies of vertebrae affected, albeit in slightly different distributions, suggests that both sexes were subject to axial loading. This pattern was distinct from the strong sexual dimorphism of lesions observed at St Andrew's or at Hull Magistrate's Court. However, both sites were monastic, and similar prevalence rates to the Fishergate House skeletons might be noted in other non-monastic populations.
Intervertebral osteochondrosis is another condition associated with intervertebral disc degeneration, characterised by rugged crescent-shaped lesions at the anterior part of the vertebral body surfaces (Kelley 1982). Comparable to Schmorl's nodes, intervertebral osteochondrosis is probably caused by stress, resulting in herniation of the discs (Plate 16, right). However, osteochondrosis is thought to develop later than Schmorl's nodes, between the second and third decade of life.
Four individuals (1.6% of individuals) suffered from intervertebral osteochondrosis, with 4% of spines affected (4% of both female and male spines) (Table 34). The lesions were characteristically crescent-shaped, with destruction of the anterior rim, and were more commonly located on the superior body surface.
| Context | Age | Sex | Area of spine | Vertebrae affected |
|---|---|---|---|---|
| 1063 | 46+ | m | thoracic vertebrae | t11 |
| 1083 | 20-25 | m | thoracic vertebrae | t6, t9 |
| 1091 | 46+ | f | thoracic and lumbar vertebrae | t10, l2, l3, l4, l5 |
| 1155 | 26-35 | f | thoracic and lumbar vertebrae | t12, l1, l3, l4, l5 |
Intervertebral osteochondrosis lesions were frequently associated with severe Schmorl's nodes, and mirrored their distribution, with a greater frequency in the central thoracic vertebrae in males and the lower thoracic and upper lumbar vertebrae in females. The resemblance between the distribution and expression of Schmorl's nodes and osteochondrosis supports the theory that these lesions have the same cause. However, the fact that intervertebral osteochondrosishas a later age of onset implies that axial compression from lifting and carrying heavy loads was an activity carried out by a large part of population at Fishergate House from young adulthood onwards.
Diffuse idiopathic skeletal hyperostosis (diffuse skeletal growth of unknown cause) (DISH), is characterised by additional bone formation at the attachment sites of muscles and ligaments, as well as on the right side of the vertebral bodies. The spinal osteophyte formation often causes fusion of a number of vertebrae, and takes a candle wax-like appearance (Plate 17, right). Although osteoarthritis and DISH are often observed in the same skeleton, they are not associated (Rogers and Waldron 2001, 359).
DISH tends to be found in those populations with a high life expectancy, and has been associated with excessive calorie intake, diabetes, obesity and ageing. It often causes the formation of ossified muscle and ligament attachments and extra bone formation at the spine to support a large figure and a deteriorating skeleton (Arriaza 1993, 275). Greater prevalence rates of DISH have been found in male monastic populations (Rogers 2000, 171), which could be due to the fact that this condition is more common in men, or older age groups, or may be related to a richer diet as compared with the lay medieval population. At the monastic sites of Hull Magistrate's Court and St Andrew's, the prevalence of DISH was 4.4% and 5.5% respectively. Additionally, a strong correlation has been found between DISH and burial in churches and chapels, with very few cases of DISH in the associated lay populations (Rogers and Waldron 2001, 361).
The lower prevalence of DISH at Fishergate House as compared with monastic populations was not unexpected. Four individuals (1.6%) with possible DISH were identified in this population (Table 35). All were mature adults with numerous ossified muscle attachments enthesopathies and fusion of at least two vertebrae, which could be indicative of the early stages of DISH. These individuals would have felt few effects of the condition, with the exception of some back stiffness. Other symptoms, such as compression of the spinal cord, or paraplegia are only found in the most extreme cases (Rogers and Waldron 2001, 359).
| Context | Age | Sex | Vertebrae fused | Other pathology |
|---|---|---|---|---|
| 1075 | 46+ | m | 5th to 6th cervical, 1st to 3rd lumbar, 4th lumbar to 1st sacral vertebra | osteoarthritis of neck; 4 rib fractures; osteoma; new bone formation on lower legs; numerous enthesopathies |
| 1139 | 46+ | m | 5th to 6th thoracic vertebra | osteoarthritis in hands, wrists; new bone formation in lower legs and skull; fracture of rib, hand phalanx, T7, T8; sinusitis; cribra orbitalia; numerous enthesopathies; weapon trauma to skull |
| 1228 | 46+ | m | 11th to 12th thoracic, 5th lumbar to first sacral vertebra | osteoarthritis of hands and neck; rib fracture; periosteal bone formation at lower legs, feet and skull; sinusitis; several enthesopathies |
| 1579 | 46+ | f | 6th to 7th thoracic, 8th to 11th thoracic vertebra | 10 rib fractures; blunt force skull injury; sinusitis; numerous enthesopathies |
Seronegative spondyloarthropathies (SNS) are chronic inflammatory conditions affecting the connective tissue of spinal and extraspinal joints (Arriaza 1993, 263). The skeletal manifestations of spondyloarthropathies include arthritic and erosive lesions, enthesopathies (bony spicules formed when muscle attachments ossify), and frequently spinal fusion or fusion of the hip and sacrum. The distribution of lesions is the main distinguishing factor between the different forms of spondyloarthropathies.
Of the four cases of fusion of the hip and sacrum, three are thought to have been congenital and are discussed above. The fourth case, involving an old middle adult female (C1312), might have been related to seronegative spondyloarthropathies. This individual suffered from slight spinal and clavicular DJD, a large number of enthesopathies,as well as a small cyst at the distal joint of the right fifth metatarsal. It is possible that this individual was suffering from a form of spondyloarthropathy which can cause fusion of the hip and sacrum. However, fusion at this joint is also common in general 'bone formers', individuals who tend to produce bone at muscle attachments and joints, rather than suffering from bone loss. The exact cause of the bone fusion, therefore, was not clear.
A second possible case of spondyloarthropathy may have been observed in a mature adult male (C1313). This individual suffered from symmetrical erosive and bone forming lesions on the toe bones (metacarpals and phalanges), as well as osteoarthritis and enthesopathies (Plate 18, right). The distribution of the lesions may be indicative of rheumatoid arthritis.
While the prevalence and distribution of DJD was similar in both males and females, the pattern of osteoarthritis in the two sexes differed considerably. A greater number of males suffered from both spinal and extra-spinal osteoarthritis than females. The distribution and prevalence of DJD could be associated with activity as well as increasing age. However, trauma was thought to be the main factor influencing the development of osteoarthritis in the older age groups. Some distinctions were observed between the sexes, with a greater prevalence of DJD in females, and a higher prevalence of osteoarthritis and fused vertebrae in males. This dimorphism may not necessarily be the result of different occupational activities. On the contrary, the similar distribution of joint disease between the sexes suggests that males and females may have been prone to different expressions of stress.
The prevalence of Schmorl's nodes per individual and vertebra may suggest that this population was accustomed to carrying or lifting heavy loads from young adulthood onwards. The distribution of Schmorl's nodes was comparable to the prevalence of spinal DJD and the distribution of intervertebral osteochondrosis, reinforcing the view that both males and females suffered severe spinal stress as a result of carrying heavy weights. The presence of Schmorl's nodes in the spines of all young men implies that those suffering from such severe physical strain were most likely to die during early adulthood.
In common with other non-monastic populations, evidence for DISH was rare at Fishergate House. Additionally, few lesions indicative of inflammatory joint disease were observed.
apc > monographs > blue bridge lane & fishergate house > artefacts & environmental > human bone:
