Parasites in ancient Egypt and Nubia: Malaria, schistosomiasis and the pharaohs.

The civilizations of ancient Egypt and Nubia played a key role in the cultural development of Africa, the Near East, and the Mediterranean world. This study explores how their location along the River Nile, agricultural practices, the climate, endemic insects and aquatic snails impacted the type of parasites that were most successful in their populations. A meta-analysis approach finds that up to 65% of mummies were positive for schistosomiasis, 40% for headlice, 22% for falciparum malaria, and 10% for visceral leishmaniasis. Such a disease burden must have had major consequences upon the physical stamina and productivity of a large proportion of the workforce. In contrast, the virtual absence of evidence for whipworm and roundworm (so common in adjacent civilizations in the Near East and Europe) may have been a result of the yearly Nile floods fertilising the agricultural land, so that farmers did not have to fertilise their crops with human faeces.

Investigating the association between intestinal parasite infection and cribra orbitalia in the medieval population of Cambridge, UK.

OBJECTIVE: Cribra orbitalia is believed to be a skeletal indicator of chronic anaemia, scurvy, rickets or related metabolic diseases. It has been suggested that it may be used as a proxy indicator for intestinal parasite infection, as parasites often cause anaemia today. Our aim is to investigate this association in the medieval population of Cambridge, UK. MATERIALS: Individuals excavated from the cemeteries of the Augustinian friary and All Saints by the Castle parish church, and aged from 7 to adulthood. METHODS: We undertook parasite analysis of the pelvic sediment and control samples of 46 burials with intact orbital roofs. RESULTS: Human roundworm (Ascaris lumbricoides) and/or whipworm (Trichuris trichiura) were identified in the pelvic sediment of 22 individuals, and cribra orbitalia noted in 11 individuals. Barnards test showed no association between parasite infection and cribra orbitalia (p = .882). CONCLUSION: We found no association between infection and cribra orbitalia infection in this medieval adult population, calling into question this hypothesis, at least for adults. SIGNIFICANCE: High or low cribra orbitalia prevalence in adults should not be used to infer rates of intestinal parasite infection. LIMITATIONS: The individuals in the study were over the age of 7, with no younger children. It is possible that only parasites which cause marked anaemia (such as hookworm, schistosomiasis or malaria) may cause cribra orbitalia, while less marked anaemia from roundworm and whipworm may not do so. SUGGESTIONS FOR FURTHER RESEARCH: Repeating this study in younger children, when most cribra orbitalia appears to form.

Tuberculosis before and after the Black Death (1346-1353 CE) in the Hospital of St John the Evangelist in Cambridge, England.

This research explores how the prevalence of tuberculosis (TB) in a medieval hospital was affected by the demographic and social changes that following the Black Death (1346-1353 CE), the initial years of the Second Plague Pandemic. To do this, skeletal remains of individuals buried at the Hospital of St John the Evangelist in Cambridge, England, that could be dated to living before (n = 77) or after (n = 55) the Black Death were assessed for evidence of TB (indicated by destructive lesions of the spine, ribs, large joints, and other recognised criteria). Overall, the odds of females having skeletal lesions caused by TB were over four times higher than males. No significant difference was detected in the prevalence rates in those who lived before and after the Black Death (7.8%, 6/77 before and 11.0%, 6/55 after). However, the odds of females having skeletal evidence of TB were over five times greater after the Black Death than they were before. These findings indicate that women may have been 1) more susceptible to TB, 2) surviving longer post-infection than men, and/or 3) that women with TB were more likely to be admitted to the Hospital especially following the Black Death. It is also possible that impairment due to TB infection may have been a contributing factor for entry into the Hospital for women but not men.

The Black Death in Hereford, England: A demographic analysis of the Cathedral 14th-century plague mass graves and associated parish cemetery.

OBJECTIVES: This study explores the paleoepidemiology of the Black Death (1348-52 AD) mass graves from Hereford, England, via osteological analysis. Hereford plague mortality is evaluated in the local context of the medieval city and examined alongside other Black Death burials. METHODS: The Hereford Cathedral site includes mass graves relating to the Black Death and a 12th-16th century parish cemetery. In total, 177 adult skeletons were analyzed macroscopically: 73 from the mass graves and 104 from the parish cemetery. Skeletal age-at-death was assessed using transition analysis, and sex and stress markers were analyzed. RESULTS: The age-at-death distributions for the mass graves and parish cemetery were significantly different (p = 0.0496). Within the mass graves, young adults (15-24 years) were substantially over-represented, and mortality peaked at 25-34 years. From 35 years of age onwards, there was little variation in the mortality profiles for the mass graves and parish cemetery. Males and females had similar representation across burial types. Linear enamel hypoplasia was more prevalent within the mass graves (p = 0.0340) whereas cribra orbitalia and tibial periostitis were underrepresented. CONCLUSIONS: Mortality within the Hereford mass graves peaked at a slightly older age than is seen within plague burials from London, but the overall profiles are similar. This demonstrates that young adults were disproportionately at risk of dying from plague compared with other age groups. Our findings regarding stress markers may indicate that enamel hypoplasia is more strongly associated with vulnerability to plague than cribra orbitalia or tibial periostitis.

Consensus guidelines on the management of musculoskeletal infection affecting children in the UK.

Aims: The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. Methods: A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children's Orthopaedic Surgery (BSCOS). Statements were only included ('consensus in') in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded ('consensus out') if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation. Results: A total of 133 children's orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached 'consensus in', 0 'consensus out', and 11 'no consensus'. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as 'consensus in', resulting in a total of 40 approved statements. Conclusion: In the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe.

Giardia duodenalis and dysentery in Iron Age Jerusalem (7th-6th century BCE).

The aim of this study was to determine if the protozoa that cause dysentery might have been present in Jerusalem, the capital of the Kingdom of Judah, during the Iron Age. Sediments from 2 latrines pertaining to this time period were obtained, 1 dating from the 7th century BCE and another from the 7th to early 6th century BCE. Microscopic investigations have previously shown that the users were infected by whipworm (Trichuris trichiura), roundworm (Ascaris lumbricoides), Taenia sp. tapeworm and pinworm (Enterobius vermicularis). However, the protozoa that cause dysentery are fragile and do not survive well in ancient samples in a form recognizable using light microscopy. Enzyme-linked immunosorbent assay kits designed to detect the antigens of Entamoeba histolytica, Cryptosporidium sp. and Giardia duodenalis were used. Results for Entamoeba and Cryptosporidium were negative, while Giardia was positive for both latrine sediments when the analysis was repeated three times. This provides our first microbiological evidence for infective diarrhoeal illnesses that would have affected the populations of the ancient near east. When we integrate descriptions from 2nd and 1st millennium BCE Mesopotamian medical texts, it seems likely that outbreaks of dysentery due to giardiasis may have caused ill health throughout early towns across the region.

Continuity in intestinal parasite infection in Aalst (Belgium) from the medieval to the early modern period (12th-17th centuries).

OBJECTIVE: To characterize patterns in the taxonomic diversity of parasites infecting the population of Aalst, Belgium, between the 12th and 17th centuries. MATERIALS: 14 sediment samples from seven cesspits dated 1100-1700 CE. METHODS: Digital light microscopy and Enzyme-linked immunosorbent assay (ELISA). RESULTS: We identified eggs of four species of helminths: whipworm (Trichuris trichiura), roundworm (Ascaris lumbricoides), Echinostoma fluke and Dicrocoelium fluke. ELISA results for protozoal parasites were negative. CONCLUSIONS: Taxonomic diversity of parasite infections remained constant from the 12th to the 17th centuries. Roundworm and whipworm, spread by poor sanitation, were dominant. Two species of zoonotic parasites were also identified, including for the first time ever in the Low Countries the Echinostoma fluke, which may have been spread by eating uncooked freshwater animal foods. SIGNIFICANCE: Analysis of sediment samples spanning such a broad chronology (six centuries) from a single city offers the opportunity to track diachronic change, which is rare in paleoparasitological studies. LIMITATIONS: We were unable to acquire samples from cesspits dating to the 14th century. SUGGESTIONS FOR FURTHER RESEARCH: Additional data from other Low Countries towns may strengthen the patterns identified in this paper. A similar approach can be used to investigate towns in different regions of the world.

Caring for the injured: Exploring the immediate and long-term consequences of injury in medieval Cambridge, England.

OBJECTIVE: To combine paleopathological and biomechanical analysis to reconstruct the impact that a severe skeletal injury had on an individual's ability to function and participate in medieval society. MATERIALS: Three medieval individuals from Cambridge, England with ante-mortem fractures to the lower limb were analyzed. METHODS: Plain X-rays were used to determine the degree of malunion, rotation and overlap of each fracture. Cortical bone architecture of the injured individuals and 28 uninjured controls were analyzed using micro-computed tomography (µCT). Clinical and functional consequences were examined using the Bioarcheology of Care framework. RESULTS: The mechanism of injury, the secondary complications, and the extent of the care received was reconstructed for each individual. Bilateral asymmetry in the cortical bone architecture revealed the long-term alterations to each individual's gait. CONCLUSION: Each of these individuals survived a severe injury resulting in chronic physical impairment, though not all would have been considered 'disabled'. SIGNIFICANCE: This research contributes to the discussion about medieval care provision and social constructions of disability by illustrating how an interdisciplinary approach provides insight into the experiences of those with physical impairments. The integration of µCT imaging within the Bioarcheology of Care model is a novel approach with great potential for application across the field. LIMITATIONS: Biomechanical analysis was restricted to cortical geometry. SUGGESTIONS FOR FUTURE RESEARCH: Further study of bilateral asymmetry in trabecular architecture could complement our understanding of altered loading modalities in past societies.

Employing radiography (X-rays) to localize lesions in human skeletal remains from past populations to allow accurate biopsy, using examples of cancer metastases.

Clinical research into biomolecules from infectious diseases and cancers has advanced rapidly in recent years, with two key areas being DNA analysis and proteomics. If we wish to understand important diseases and their associated biomolecules in past populations, techniques are required that will allow accurate biopsy of lesions in excavated human skeletal remains. While locating lesions visible on the surface of a bone is simple, many lesions such as cancer metastases are located in the medulla of bones, unseen on visual inspection. Here, we use two novel image guided techniques to investigate how plain radiographs may improve accuracy in the localization of lesions within bones from medieval individuals. While both techniques were effective, we found the grid technique required fewer radiographs than the pointer technique to employ and so was responsible for a lower overall radiation dose. We then discuss methods available for biopsy in archeological bone and how the optimal location for the biopsy of malignant lesions will vary depending upon whether the tumor is blastic or lytic in nature. Limitations of this X-ray guided approach include that not all cancer metastases are visible on plain radiographs, as erosion of cortical bone is frequently required for visualization of lytic metastases using this imaging modality.

Intestinal parasite infection in the Augustinian friars and general population of medieval Cambridge, UK.

OBJECTIVE: To investigate how lifestyle may have impacted the risk of contracting intestinal parasites in medieval England . Regular clergy (such as those living in monasteries) and the lay population form interesting groups for comparison as diet and lifestyle varied significantly. Monasteries were built with latrine blocks and hand washing facilities, unlike houses of the poor. MATERIALS: Sediment samples from the pelvis, along with control samples from feet and skull, of 19 burials of Augustinian Friars (13th-16th century), and 25 burials from All Saints by the Castle parish cemetery (10th-14th century), Cambridge. METHODS: We analysed the sediment using micro-sieving and digital light microscopy to identify the eggs of intestinal parasites. RESULTS: Parasite prevalence (roundworm and whipworm) in the Augustinian friars was 58%, and in the All Saints by the Castle parishioners just 32% (Barnards Test score statistic 1.7176, p-value 0.092). CONCLUSIONS: It is interesting that the friars had nearly double the infection rate of parasites spread by poor hygiene, compared with the general population. We consider options that might explain this difference, and discuss descriptions and treatment of intestinal worms in medical texts circulating in Cambridge during the medieval period. SIGNIFICANCE: This is the first study to compare prevalence of parasite infection between groups with different socioeconomic status from the same location. LIMITATIONS: Quality of egg preservation was suboptimal, so our data may under-represent the true prevalence. SUGGESTIONS FOR FURTHER RESEARCH: Larger studies with greater statistical power, covering different time periods and regions.

Intestinal parasites in the Neolithic population who built Stonehenge (Durrington Walls, 2500 BCE).

Durrington Walls was a large Neolithic settlement in Britain dating around 2500 BCE, located very close to Stonehenge and likely to be the campsite where its builders lived during its main stage of construction. Nineteen coprolites recovered from a midden and associated pits at Durrington Walls were analysed for intestinal parasite eggs using digital light microscopy. Five (26%) contained helminth eggs, 1 with those of fish tapeworm (likely Dibothriocephalus dendriticus) and 4 with those of capillariid nematodes. Analyses of bile acid and sterol from these 5 coprolites show 1 to be of likely human origin and the other 4 to likely derive from dogs. The presence of fish tapeworm reveals that the Neolithic people who gathered to feast at Durrington Walls were at risk of infection from eating raw or undercooked freshwater fish. When the eggs of capillariids are found in the feces of humans or dogs it normally indicates that the internal organs (liver, lung or intestines) of animals with capillariasis have been eaten, and eggs passed through the gut without causing disease. Their presence in multiple coprolites provides new evidence that internal organs of animals were consumed. These novel findings improve our understanding of both parasitic infection and dietary habits associated with this key Neolithic ceremonial site.

Assessing the relative benefits of imaging with plain radiographs and microCT scanning to diagnose cancer in past populations.

OBJECTIVE: To determine the degree to which plain radiographs (x-rays) and microCT scans can improve accuracy in the diagnosis of cancer in human remains from past populations. MATERIALS: The skeletal remains of 143 individuals from medieval Cambridgeshire, dating from 6th-16th century CE. METHODS: Visual inspection of the skeletons for lesions compatible with malignancy, coupled with plain radiographs and microCT scans of the pelvis, femora and vertebra. RESULTS: Three individuals had visually apparent metastases on their skeletons. Plain radiographs did not identify further individuals with cancer, but did show further lesions in bones with normal external appearance. MicroCT scans identified cancer in two further individuals with normal visual appearance and normal plain radiographs. CONCLUSIONS: Imaging human skeletal remains increases the detection rate of cancer in human skeletal remains. We found microCT scanning to be a much more sensitive imaging modality than plain radiography. It improved our diagnostic accuracy and enabled us to more reliably distinguish between malignant lesions and taphonomic change. SIGNIFICANCE: Future studies investigating the prevalence and nature of malignancy in past populations would benefit from systematic microCT scanning of pelvis, femora and vertebrae of skeletons to optimise their diagnostic accuracy. LIMITATIONS: MicroCT scanning is more expensive than plain radiographs, and may not be easily accessible to biological anthropologists. SUGGESTIONS FOR FURTHER RESEARCH: To apply this approach to skeletal series from different time periods and geographical regions, where the types of cancer existing in the local population may differ from those we studied in medieval Britain.

Weapon injuries in the crusader mass graves from a 13th century attack on the port city of Sidon (Lebanon).

Archaeological excavations close to St Louis' castle in Sidon, Lebanon have revealed two mass grave deposits containing partially articulated and disarticulated human skeletal remains. A minimum of 25 male individuals have been recovered, with no females or young children. Radiocarbon dating of the human remains, a crusader coin, and the design of Frankish belt buckles strongly indicate they belong to a single event in the mid-13th century CE. The skeletal remains demonstrate a high prevalence of unhealed sharp force, penetrating force and blunt force trauma consistent with medieval weaponry. Higher numbers of wounds on the back of individuals than the front suggests some were attacked from behind, possibly as they fled. The concentration of blade wounds to the back of the neck of others would be compatible with execution by decapitation following their capture. Taphonomic changes indicate the skeletal remains were left exposed for some weeks prior to being collected together and re-deposited in the defensive ditch by a fortified gateway within the town wall. Charring on some bones provides evidence of burning of the bodies. The findings imply the systematic clearance of partially decomposed corpses following an attack on the city, where adult and teenage males died as a result of weapon related trauma. The skeletons date from the second half of the Crusader period, when Christian-held Sidon came under direct assault from both the Mamluk Sultanate (1253 CE) and the Ilkhanate Mongols (1260 CE). It is likely that those in the mass graves died during one of these assaults.

The greatest health problem of the Middle Ages? Estimating the burden of disease in medieval England.

OBJECTIVE: To identify the major health problems of the Middle Ages. Bubonic plague is often considered the greatest health disaster in medieval history, but this has never been systematically investigated. MATERIALS: We triangulate upon the problem using (i) modern WHO data on disease in the modern developing world, (ii) historical evidence for England such as post-medieval Bills of Mortality, and (iii) prevalences derived from original and published palaeopathological studies. METHODS: Systematic analysis of the consequences of these health conditions using Disability Adjusted Life Years (DALYs) according to the Global Burden of Disease methodology. RESULTS: Infant and child death due to varied causes had the greatest impact upon population and health, followed by a range of chronic/infectious diseases, with tuberculosis probably being the next most significant one. CONCLUSIONS: Among medieval health problems, we estimate that plague was probably 7th-10th in overall importance. Although lethal and disruptive, it struck only periodically and had less cumulative long-term human consequences than chronically endemic conditions (e.g. bacterial and viral infections causing infant and child death, tuberculosis, and other pathogens). SIGNIFICANCE: In contrast to modern health regimes, medieval health was above all an ecological struggle against a diverse host of infectious pathogens; social inequality was probably also an important contributing factor. LIMITATIONS: Methodological assumptions and use of proxy data mean that only approximate modelling of prevalences is possible. SUGGESTIONS FOR FURTHER RESEARCH: Progress in understanding medieval health really depends upon understanding ancient infectious disease through further development of biomolecular methods.

Fancy shoes and painful feet: Hallux valgus and fracture risk in medieval Cambridge, England.

OBJECTIVE: Hallux valgus, the lateral deviation of the great toe, can result in poor balance, impaired mobility and is an independent risk factor for falls. This research aims to compare the prevalence of hallux valgus in subpopulations of medieval Cambridge, England, and to examine the relationship between hallux valgus and fractures to examine the impact of impaired mobility and poor balance caused by this condition. MATERIALS: 177 adult individuals from four cemeteries located in Cambridge, England. METHODS: Human remains were macroscopically and radiographically assessed. RESULTS: Hallux valgus was identified in 18 % of individuals and was significantly more common during the 14th-15th centuries than the 11th-13th centuries. The highest prevalence was observed in the friary (43 %), followed by the Hospital (23 %), the rurban parish cemetery (10 %), and the rural parish cemetery (3%). Fractures from falls were significantly more common in those with hallux valgus than those without. CONCLUSION: The increased prevalence of hallux valgus identified in individuals from the 14th to 15th centuries coincided with the adoption of new footwear with pointed toes. Those that adopted this fashion trend appear to have been more likely to develop balance and mobility problems that resulted in an increased risk of falls. SIGNIFICANCE: This is the first study to explore the relationship between foot problems and functional ability by studying hallux valgus in archaeological assemblages. LIMITATIONS: Falls are complex and determining the mechanism of injury in human skeletal remains is not always possible. FURTHER RESEARCH: Fracture prevalence rates may have been affected by biological factors and underlying pathological conditions.

Gout and 'Podagra' in medieval Cambridge, England.

OBJECTIVE: To estimate the prevalence rate of gout and to explore the social factors that contributed to its development in the various sub-populations in medieval Cambridge. MATERIALS: 177 adult individuals from four medieval cemeteries located in and around Cambridge, UK. METHODS: Lesions were assessed macroscopically and radiographically. Elements with lytic lesions were described and imaged using micro-computed tomography (µCT) to determine their morphology. RESULTS: Gout was identified in 3 % of the population. Individuals buried in the friary had highest prevalence (14 %), with low prevalence rates in the Hospital (3 %) and town parish cemetery (2 %), with no cases in the rural parish cemetery. Gout was more prevalent during the 14th-15th centuries than the 10th-13th centuries. CONCLUSION: The high prevalence rate of gout in the friary is at least partly explained by the consumption of alcohol and purine-rich diets by the friars and the wealthy townsfolk. Medieval medical texts from Cambridge show that gout (known as podagra) was sometimes treated with medications made from the root of the autumn crocus. This root contains colchicine, which is a medicine that is still used to treat gout today. SIGNIFICANCE: This is one of the first studies to assess the epidemiology of gout in medieval England and suggests that gout varied with social status. LIMITATIONS: Our sample size precludes statistical analysis. SUGGESTIONS FOR FURTHER RESEARCH: Additional studies that assess the epidemiology of gout in medieval Europe is needed in order to be able to fully contextualize these findings.

The prevalence of cancer in Britain before industrialization.

BACKGROUND: To plan for cancer services in the future, the long view of cancer prevalence is essential. It might be suspected that cancer prevalence before tobacco and industrial revolution pollutants was quite different to today. METHODS: To quantify the degree to which cancer prevalence may be changing over time, the authors analyzed 143 skeletons from 6 cemeteries from the Cambridge area (6th-16th centuries). Visual inspection coupled with screening using both plain radiographs and computed tomography scans was used to detect malignant lesions. RESULTS: A total of 3.5% of individuals showed evidence for metastases. Factoring in modern data for the proportion of those with cancer that die with bone metastases, this suggests a minimum prevalence of all cancers at the time of death in medieval Britain to be approximately 9% to 14% of adults. CONCLUSIONS: This figure compares with a 40% to 50% prevalence of cancer at the time of death for modern Britain. The difference may be explained by the effects of modern carcinogens, the spread of viruses that trigger malignancy, industrial pollutants, and longer life expectancy. LAY SUMMARY: Until now, no one has been able to work out how common cancer was before the time people were exposed to tumor-inducing chemicals from tobacco and industrial factories. In this novel study, the authors have determined the percentage of people living in medieval Britain who had cancer metastases to bone at the time of their death and then compared that with modern data. It was found that cancer was approximately 25% as common in medieval times as it is today. This article suggests cancer was much more widespread in medieval times than was previously realized.

Acute Musculoskeletal Sports Injuries in School Age Children in Britain.

OBJECTIVES: To determine the relative number of acute musculoskeletal injuries sustained by children due to different sports in a region of the UK, and assess the burden upon the NHS, through a cross sectional study. METHODS: Collection of data for every child aged 6-18 seen at the Peterborough City Hospital fracture clinic, whose sports injury was from 1st September 2018 - 31st August 2019 (1 school year; n=689). Data was gathered throughout the year by three children's orthopaedic surgeons, who consulted the clinic records, notes and x-rays of all children who had attended clinic. RESULTS: Boys were 2.7 times more likely to sustain injury than girls. Children aged 6-9 had few injuries (mean 24 injuries each year group), 10-15 had a large number of injuries (mean 84), and 16-18 again had few injuries (mean 35). Football and rugby were responsible for the majority of injuries (61% between them), as well as the majority of physiotherapy appointments (72%). Sports with the highest likelihood that an injury will be sufficiently serious to require surgery were equestrian (42% of injuries required surgery), gymnastics (27%), ice skating (25%) and rugby (22%). Popular sports in which injuries were relatively rare include swimming, athletics, cricket, hockey, tennis and badminton. CONCLUSION: The sports that caused the most injuries were football and rugby. Considering relative participation in different sports, it is clear that rugby has a disproportionate number of musculoskeletal injuries in total, of severe injuries requiring surgery, and requiring rehab from physiotherapy.