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PRA00fr(i-xvi;1-2;5bls)_UB 10/11/12 10:01 AM Page i

PHOTOGRAPHIC REGIONAL
ATLAS OF BONE DISEASE
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PRA00fr(i-xvi;1-2;5bls)Q8.0_UB 12/6/12 4:01 PM Page iii

Third Edition

PHOTOGRAPHIC
REGIONAL ATLAS OF
BONE DISEASE
A Guide to Pathologic and Normal Variation
in the Human Skeleton

By

ROBERT W. MANN, PH.D., D-ABFA, FCPP

and

DAVID R. HUNT, PH.D., D-ABFA

With a Foreword by
O’Brian C. Smith

With an Introduction by
Donald Ortner
PRA00fr(i-xvi;1-2;5bls)_UB 10/11/12 10:01 AM Page iv

Published and Distributed Throughout the World by

CHARLES C THOMAS • PUBLISHER, LTD.

2600 South First Street
Springfield, Illinois 62704

This book is protected by copyright. No part of

it may be reproduced in any manner without
written permission from the publisher.

2005 by CHARLES C THOMAS • PUBLISHER, LTD.

ISBN 978-0-398-08826-2 (hard)

ISBN 978-0-398-08827-9 (ebook)

Library of Congress Catalog Card Number: 2012016071

With THOMAS BOOKS careful attention is given to all details of manufacturing

and design. It is the Publisher's desire to present books that are satisfactory as to their
physical qualities and artistic possibilities and appropriate for their particular use.
THOMAS BOOKS will be true to those laws of quality that assure a good name
and good will.

Printed in the United States of America

UB-R-3

Library of Congress Cataloging-in-Publication Data

Mann, Robert W
Photographic regional atlas of bone disease : a guide to pathologic and normal variation
in the human skeleton / by Robert W. Mann and David R. Hunt ; foreword by O'Brian C.
Smith ; introduction by Donald Ortner. — 3rd ed.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-398-08826-2 (hard) — ISBN 978-0-398-08827-9 (ebook) 1. Bones—Diseases—
Atlases. 2. Paleopathology—Atlases. I. Hunt, David R. II. Title.

RC930.4.M35 2012
616.7'100222—dc22
201201671
PRA00fr(i-xvi;1-2;5bls)_UB 10/11/12 10:01 AM Page v

Photo: Chip Clark

Dedicated to the memory of

Donald J. Ortner. . . visionary,
luminary and friend.
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PRA00fr(i-xvi;1-2;5bls)_UB 10/11/12 10:01 AM Page vii

FOREWORD

Art is I, Science is We. — Claude Bernard

nthusiasm. The most motivating force in a student is enthusiasm. Many

E bring it with them, already on fire for their particular area of interest.
Most though are infected with it by their instructors and fellow students as a
sense of discovery, for advancement and competency develops. Enthusiasm
dwarfs things petty to science; egos, attitudes, personal agendas, and the like.
It creates an aura of academic purity, an environment without fear where
"we" is paramount, and "I" becomes a measure of capacity, not importance.
It is a time where we can be smart together and we can be dumb together
without pride or fear.
Cultivating enthusiasm is one of the hardest tasks for an educator, espe-
cially in students just entering an area of study. Many disciplines have their
own language, because it requires precisely defined concepts to advance the
field. The introductory student needs to acquire some of this to be facile in
developing his/her knowledge and thinking, but too much can intimidate and
dampen enthusiasm. The educator, well versed in terminology, needs to in-
troduce his/her topic in the language of the layman in order to assure com-
munication. This latter is not an easy task because precision of concept
suffers.
It is a bold step then for any introductory text to be written especially for
the entering student. Colleagues who have already achieved their knowledge-
base can always be critical of the authors’ license and charge oversimplifica-
tion; and in part will always be right. My reply is that I've rarely found
reference books to have a well-thumbed appearance. If I have to choose be-
tween precision and enthusiasm for the new student, it will always be enthu-
siasm! If the fire gets stoked, the opportunity for full potential is achieved.
Let the above be enough to explain this book to my colleagues. I hope too,
that they will learn some things from the authors, because I did. For you, the
most important reader, the newest generation, I welcome you as colleagues
and invite you to these pages. Read! Enjoy! Discover! Think!

O'BRIAN C. SMITH, M.D.

Professor of Pathology;
University of Tennessee School of Medicine,
Knoxville
Chief Medical Examiner;
State of Tennessee

vii
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INTRODUCTION

areful description and classification are basic methodological tools in all

C categories of science. This is particularly the case in biomedical research
where substantial resources are invested in a continuous process of refining
diagnostic criteria (classification) for various diseases. The field of paleo-
pathology has been slow in confronting some long-standing problems in
description and classification and this has limited its development. The result
is a substantial proportion of the existing literature that is of minimal value in
clarifying many of the broader questions that must be addressed if paleo -
pathology is to reach its full potential as a legitimate biomedical discipline.
For example, it would be very helpful to have a database that provides
information on the antiquity, geographical distribution and evolutionary
trends of disease. We also need data that will help to clarify the evolution of
complex relationships that exist between the many factors that affect the
human response to disease, including: (1) the pathogenic agent, (2) environ-
mental factors (e.g., air pollution) that affect health, (3) nutrition and (4) the
immune response of a patient to disease. However, without a clearly defined
and generally accepted descriptive terminology and classificatory system it is
difficult, if not impossible, to compare the research of one scientist with that
of another in building a relevant base of data.
An important contribution to the study of skeletal paleopathology would
be the development of a rigorous method to describe the abnormal conditions
encountered in archeological human skeletons. It is both surprising and frus-
trating that after 150 years of research in paleopathology there is still much
to do in creating a careful and comprehensive descriptive terminology, as
well as a general classification of the abnormal conditions encountered in
skeletal specimens. Much of how we describe pathological conditions in
archeological skeletons is derivative of medical and particularly orthopedic
nomenclature and classificatory systems. These systems continue to develop
and staying conversant with current usage is a challenging exercise. The
major problem, however, is not one of semantics. Rather it is that many of the
lesions and their distribution patterns in archeological dry bone specimens
bear minimal relationship to descriptive and classificatory features that are
central in clinical orthopedic practice. What is crucial for paleopathology is a
nomenclature and classificatory system that integrates all of the pathological
information that is apparent in skeletal paleopathological specimens. Such a
system would necessarily include orthopedic terms and classification where
the features were closely related to those used in a clinical setting. There are,
however, occasional conditions in paleopathological cases that are not well

ix
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x Photographic Regional Atlas of Bone Disease

known in clinical orthopedic practice and a precise classificatory system

might demonstrate relationships that previously had not been understood.
In working with both professional colleagues and graduate students I have,
for many years, emphasized the importance of first describing carefully what
one sees in cases of skeletal paleopathology. Careful description is timeless and,
if done well, forever gives future readers of reports the option of reinterpreting
your conclusions (i.e., diagnoses). Demographic data, including age and sex, are
important factors in interpreting descriptive information. However, the most
important element in paleopathological research is the basic description of
abnormal bone including the type and distribution pattern within the skeleton.
There are four basic abnormalities of bone: (1) abnormal size, (2) abnormal
shape, (3) abnormal bone formation and, (4) abnormal bone destruction.
There are additional features associated with these general abnormalities that
provide helpful supplemental information. For example, is the abnormal
bone formation poorly organized (this typically means rapid growth) or well
organized (usually slow growth)? Do destructive lesions have well-defined
margins with evidence of well-organized bony repair (circumscribed and gen-
erally less aggressive) or poorly-defined margins (permeative and generally
more aggressive)? These and other features are all critical elements in any
interpretation of a paleopathological case of skeletal disease.
The location of lesions within the skeleton provides an important link with
clinical experience but one needs to be cautious in making such associations.
In dry-bone paleopathological cases one often sees lesions that would not be
apparent in clinical radiographs and are thus not well documented in the
medical descriptive and classificatory systems. Indeed the added information
on skeletal lesions is one of the significant potential contributions that careful
study of paleopathological cases can make to a more complete understanding
of the skeletal manifestations in orthopedic pathology. A pathology based on
dry-bone conditions also means that some distribution patterns of abnormal
tissue within a pathological skeleton will vary from patterns established on
the basis of radiology in living patients.
Careful description is not easy and I do not wish to underestimate the
difficulty of the process. Nevertheless, most people can, with discipline, learn
to recognize the essential features of bone reaction to disease. The first step is,
of course, a thorough knowledge of normal gross anatomy of bone at all ages
from fetal through old age. Archeological skeletal samples are a wonderful
source of anatomical knowledge since the entire age spectrum is usually
represented. Classification or diagnosis is a much more complicated matter
and for many cases encountered by the researcher investigating paleopathol-
ogy, years of experience and a comprehensive knowledge of orthopedic
pathology may be necessary and, even so, may not be possible.
For those conducting research on skeletal paleopathology great attention
needs to be paid to using a well defined and widely recognized terminology
in describing pathological skeletal lesions. Excellent reference materials in
radiology exist such as Resnick's five-volume work (2002). The second edition
of my book on human skeletal paleopathology (Ortner 2003) may also be
helpful in highlighting both the terminology and the diagnostic options for
some cases of skeletal disease.
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Introduction xi

I am optimistic that further advances will be made in developing descriptive

and classificatory methodology for paleopathology in the near future. In the
meantime it is important to use descriptive terms and modifiers that are part
of the general lexicon we all share. Bone addition, bone destruction, porous
bone, and destructive lesions are examples of terms that are descriptive and
have wide recognition in many disciplines and I encourage their use. Jargon,
is one of the biggest barriers to effective communication that exists and should
be eliminated or, at the very least, kept to a minimum. At some point, how-
ever, you will need to acquire a working knowledge of medical terminology if
only to understand and interpret the existing literature on paleopathology
and communicate with medically trained colleagues.
The third edition of the Regional Atlas of Bone Disease is a new attempt to
assist the beginning skeletal paleopathologist to recognize some of the more
common pathological conditions that may be encountered in dry-bone speci-
mens. The authors have provided new examples and cases to illustrate their
points but continue to insist that their endeavor be viewed as an initial step
in any classificatory process. This is wise counsel, given the complexity of
classification. One of the fundamental problems for any classificatory system is
that the bone reaction to disease is limited. In view of this it is not surprising
that a given pathological condition (i.e., osseous response) may be the result
of any one of several pathological processes.
The reader should also be aware of the strengths and weaknesses of a
regional approach to skeletal paleopathology. Archeological skeletal samples
often do not have complete skeletons. This is particularly true of older museum
collections where only the skull and mandible may have been recovered.
However, even where an attempt was made to excavate the entire skeleton
the result is usually only partially successful. In this context a regional review of
pathological conditions may be the only one possible and is certainly helpful.
It is also true that many pathological conditions occur in a single location in
the skeleton (solitary or unifocal conditions). A regional focus is generally
adequate for such lesions.
However, a regional approach is less helpful in multifocal pathological
conditions. In this type of skeletal paleopathology, the distribution pattern of
abnormal bone is a critical element in classification and the user of a regional
approach will need to reconstruct the overall pattern by carefully reviewing
the information for each region of the skeleton. A review of the distribution
pattern of abnormal bone is important for classification but also contributes
to the general understanding of pathogenesis in orthopedic disorders.
Despite this cautionary note, the beginning skeletal paleopathologist should
find the new edition of the Regional Atlas a helpful starting point when he or
she encounters a skeletal abnormality in archeological burials. Remember,
however, first provide a careful and detailed description of the abnormalities
you see including the nature of the abnormalities and their location in the
skeleton. An attempt at diagnosis can then be made with the assurance that
others will at least have the option of reaching a different diagnostic conclu-
sion on the basis of the descriptive information you have provided should
that be appropriate. The authors' counsel to seek advice on diagnosis from
specialists in skeletal disease is wise. Keep in mind, however, that very few
PRA00fr(i-xvi;1-2;5bls)_UB 10/11/12 10:01 AM Page xii

xii Photographic Regional Atlas of Bone Disease

medical specialists have experience with dry-bone specimens and are often
as baffled by a pathological case as is the osteologist. The orthopedist does,
however, have the advantage of knowing what most of the diagnostic options
are and this is a very useful point of departure.

DONALD ORTNER, Ph.D.

Department of Anthropology
National Museum of Natural History Smithsonian
Institution
PRA00fr(i-xvi;1-2;5bls)_UB 10/11/12 10:01 AM Page xiii

ACKNOWLEDGMENTS

T he authors would like to extend a special debt of gratitude to Dr. Donald

Ortner, Dr. Douglas W. Owsley, Mr. Paul S. Sledzik, and Mr. Sean P.
Murphy to this enterprise. Each of these scientists played a significant role
not only in the development of this book, but its contents. Dr. O'Brian C.
Smith contributed substantially to writing the Foreword and Chapter IV. The
authors would also like to express their gratitude to Drs. J. Lawrence Angel,
Ethne Barnes, William M. Bass, Hugh E. Berryman, Bruce Bradtmiller, Ms.
Kari Sandness Bruwelheide, Mr. Henry W. Case, Drs. Leslie E. Eisenberg,
Eugene Giles, Thomas D. Holland, Lee Meadows Jantz, Richard L. Jantz,
Ms. Erica Bubniak Jones, Drs. Marc A. Kelley, Linda Klepinger, Ms. Marilyn
R. London, Drs. Keith A. Manchester, Marc S. Micozzi, Bruce Ragsdale,
Charlotte A. Roberts, Jeno I. Sebes, T. Dale Stewart, Douglas H. Ubelaker,
and P. Willey. It was through their friendship, teaching, and professional
guidance that this book came to fruition. All illustrations were drawn by
Robert W. Mann, except Figure 124 (Elizabeth C. Lockett) and Figure 93b
(Neil Fallon). Drawings and most of the photographs were based on anatomical
specimens at the Smithsonian Institution and Khon Kaen University Department
of Anatomy, Khon Kaen, Thailand. Unless stated otherwise, all photographs
were taken by the authors. Mr. Chip Clark, of the National Museum of Nat-
ural History, Smithsonian Institution, Mr. Hugh E. Tuller and Dr. Joseph T.
Hefner of the Central Identification Laboratory graciously allowed us to
reproduce several of their photographs. Dr. Panya Tuamsuk, Dr. Kamoltip
Brown and Dr. Kowit Chaisiwamongkol provided unrestricted access to the
Osteological Collection and records at Khon Kaen University, Thailand. Ms
Anna Dhody and Dr. Robert Hicks of the Mütter Museum in Philadelphia,
Pennsylvania facilitated access to their unique osteological and anatomical
collections and provided helpful insights on many of the specimens. Ms. Evi
Numen, Exhibits Manager of the Mütter Museum graciously provided us
with the photographs of Mr.Harry Eastlack that grace the front and back
covers of this book. Dr. Janet Monge and her assistant Mr. Paul Mitchell of the
University of Pennsylvania Museum of Archaeology and Anthropology in
Philadelphia allowed access to the Morton Collection and provided assistance
and historical information on many of the specimens. The opinions expressed
in the Regional Atlas are the sole responsibility of the authors. Last but certainly
not least we thank our wives, Vara J. Mann and Kim Wells, and our parents
Adele D. Mann and Arlys Roehm Hunt and James C. Hunt for their love and
support.

xiii
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CONTENTS

Page
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter
I. U SING THE P HOTOGRAPHIC REGIONAL ATLAS . . . . . . . . . . . . . . . . . . . . . . . . 3
II. A B RIEF H ISTORY OF PALEOPATHOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
III. P REPARING F OR A BASIC PALEOPATHOLOGICAL ANALYSIS . . . . . . . . . . . . . . 9
IV. F UNDAMENTALS OF BONE F ORMATION AND REMODELING . . . . . . . . . . . . . 13
The Necessity of Knowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

V. DISEASES OF I NDIVIDUAL BONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Skull and Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Vertebra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Rib . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Sacrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Innominate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Manubrium and Sternum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Clavicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Scapula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Radius and Ulna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Fibula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Patella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

VI. F UNGAL I NFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

VII. TREPONEMATOSIS (SYPHILIS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
VIII. TUMORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
IX. P ERIMORTEM F RACTURES VERSUS P OSTMORTEM B REAKAGE . . . . . . . . . . . . 197

xv
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xvi Photographic Regional Atlas of Bone Disease

X. E NTHESEAL CHANGE (“M USCLE MARKERS OF STRESS”) . . . . . . . . . . . . . . . . . 203

XI. CASE REPORT: DIFFERENTIAL DIAGNOSIS OF S EVERE DIFFUSE

S KELETAL PATHOLOGY IN AN ADULT THAI MALE . . . . . . . . . . . . . . . . . . . . . 213

XII. THE H UMAN S KELETON (VENTRAL AND D ORSAL VIEWS) . . . . . . . . . . . . . . 223

XIII. M USCLE ATTACHMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Selected Muscle Attachment Sites (Ventral View) . . . . . . . . . . . . . . . . . . . . . 226
Selected Muscle Attachment Sites (Dorsal View) . . . . . . . . . . . . . . . . . . . . . . 228

XIV. P LATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
PRA00fr(i-xvi;1-2;5bls)_UB 10/11/12 10:01 AM Page 1

PHOTOGRAPHIC REGIONAL
ATLAS OF BONE DISEASE
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Chapter I

USING THE PHOTOGRAPHIC

REGIONAL ATLAS

T he information contained in the Photographic

Regional Atlas of Bone Disease — herein referred
to as the Regional Atlas — is based on paleo-
the Regional Atlas is Chapter V. This chapter
deals with specific diseases affecting each bone in
the body, beginning with the skull and progress-
pathological examination of more than 10,000 ing down the skeleton. Accompanying some
complete or nearly complete skeletons from lesion descriptions is a statement of the relative
archaeological sites and forensic investigations frequency (e.g., uncommon to rare finding) or
throughout the world. The majority of these percentage that one might expect to find in most
studies are from prehistoric collections from archaeological skeletal samples, in most cases for
North America, particularly from the Great Native American groups since the majority of the
Plains, Pacific Coastal regions and the Northeast- author’s studies encompassed these populations.
ern United States; historic cemeteries and burials References cited within a sentence indicate that
from Canada, Louisiana, Maryland, Nevada, the information was derived from these sources.
Virginia, Washington, D.C. (including War of References at the end of a paragraph (following
1812, Civil War soldiers and iron coffin burials); the period or “cf.”) were included as additional
as well as over two hundred forensic cases in- sources for the reader seeking additional informa-
cluding Americans missing in action (MIA). tion. Many of these references are the seminal re-
Skeletal collections from Africa, Australia, Central ports of research for these pathological conditions
Asia, and South America have also been investi- or anomalies or extensively cover the condition.
gated by the authors. Contemporary skeletal It is not necessary to reiterate the information
samples have been studied by the authors from published and available in these volumes.
the Hamann-Todd (Cleveland, Ohio), Robert J. The reader will find that many of the references
Terry Anatomical and George S. Huntington used in this book were culled from the medical,
Anatomical (Smithsonian Institution) collections, clinical, anatomical, and radiological literature
and the Osteology Collection in the Department rather than the anthropological literature. The
of Anatomy, Faculty of Medicine at Khon Kaen reason is multiple. First, clinical studies and case re-
University, Khon Kaen, Thailand. ports provide information based on findings, often
The Regional Atlas approaches the recognition accompanied by patient histories, known age, race,
of disease according to the bone affected. The and sex of the individuals in living groups. Anthro-
format of this handbook begins with a descrip- pological studies, in comparison, tend to focus on
tion of how to use the Regional Atlas (Chapter I), samples of unknown age, race and sex individuals
followed by a brief history of paleopathology in recent or ancient groups. Second, most diseases
(Chapter II). Chapter III gives step-by-step in- can be specifically identified in modern clinical
structions on how the authors conduct a paleo - studies, but not necessarily in ancient remains.
pathological analysis. Chapter IV briefly covers Chapter VI provides information on fungal
the mechanics of bone remodeling. The bulk of infections. The treponematoses (i.e., syphilis and

3
PRA01(3-6;6bl)_UB 10/11/12 1:29 PM Page 4

4 Photographic Regional Atlas of Bone Disease

allied conditions) are summarized in Chapter VII. skeleton, the more we are humbled by how
Chapter VIII briefly discusses tumors, perhaps much there is still to learn. Having worked at the
the most difficult skeletal condition to be diag- Smithsonian Institution and afforded the oppor-
nosed. Chapter IX discusses perimortem fractures tunity to peruse the vast skeletal collection and
and postmortem breakage. Chapters VI through Smithsonian libraries over the years, we are in
IX are designed to only briefly present the effects awe of the endless possibilities for the subtle and
of these pathological skeletal conditions on the not-so-subtle variation present in the human
human skeleton — the references cited in those skeleton, This awe, of course, focuses not only on
chapters much more extensively cover these the extent of skeletal variation, but its etiology, as
particular diseases and should be referred to by well as geographical and temporal distribution.
the reader for more in-depth research. In order to stay current, updated references
Chapter X, “Entheseal Change,” covers a and findings in the field of archaeology, paleo-
much discussed and disputed topic variously pathology, anatomy, and medicine have been in-
identified as muscle markers of stress, entheso- corporated into the Regional Atlas since the 2005
phytes, and activity-induced stress markers, to edition. To provide a more historical perspective
name but a few. Chapter XI presents a case that helps us “trace our roots” in paleopathology
report reflecting the advanced stages of a disease and anatomy, the authors have combed the early
rarely encountered in osteological collections, literature in search of the first reported examples
reflecting the body’s extraordinary capacity to of some pathological lesions and conditions bear-
deal with a disease condition that at first blush ing the names (eponyms) of their “discoverers.”
appears to be incompatible with life. As an These groundbreaking anatomists and physi-
anatomical overview, dorsal and ventral views of cians include Jean-Martin Charcot (1825–1893;
the human skeleton are provided in Chapter Charcot’s joint), James Paget (1814–1899; Paget’s
XII. The major muscle attachments are illus- disease), Bartolomeo Eustachi (c. 1524–1574;
trated in Chapter XIII. Chapter XIV consists of Eustachian tube), Antonio Pacchioni (1665–
many “larger than life” color photographs (plates) 1726; Pacchionian depressions), and Sir Percival
of common, uncommon and even rare diseases, Pott (1714–1788; Pott’s disease of the spine), to
lesions, and a few non-metric traits that are name but a few. This book also reflects the
sometimes confused with lesions that one might authors’ own experiences examining more than
encounter in a skeletal sample. These color pho- 10,000 human skeletons from around the world
tographs expand our knowledge of disease and since the Regional Atlas was first published in 1990.
allow the reader to see lesions with sufficient Diseases, lesions, and skeletal anomalies too rare
clarity and detail that might otherwise be missed to be expected to be encountered in a routine
in black and white or smaller photographs. The skeletal analysis have been removed and replaced
authors have learned firsthand how frustrating with those that might be expected to be encoun-
it is to try and find a lesion or subtle skeletal tered in most skeletal collections around the world.
feature referred to in a figure caption, but not It should be remembered that no text could
highlighted in the image or photo. fully or even adequately cover or explain the eti-
This book was rewritten after being "field ology or geographical distribution of every disease,
tested" for more than two decades by physicians, anomaly, or normal anatomical variant present in
students, and paleopathologists around the the human skeleton; the present text is no excep-
world. The evolution of this book, built upon the tion. While some topics in the Regional Atlas are
shoulders of such luminaries as Thomas Dwight, discussed in great detail, others are conspicuously
Aleš Hrdlička, J. Lawrence Angel and T. Dale brief owing to their extreme difficulty in differential
Stewart, was the result of trial and error, count- diagnosis, or rarity in most skeletal collections
less trips to medical and other libraries, web (e.g., tumors). One goal of the Regional Atlas was to
searches, and a learning process that is ongoing. include the findings and hypotheses of contempo-
Truly, the more we the authors study the human rary clinical practitioners (e.g., paleopathologists,
PRA01(3-6;6bl)_UB 10/11/12 1:30 PM Page 5

Using the Photographic Regional Atlas 5

radiologists, etc.) to supply the reader with a primarily with the skeleton, the Journal of Anatomy
number of interpretations from which to choose. and Physiology and Spine (as well as numerous
Such an approach also serves to inform the reader radiology journals) that cover a vast array of
of the complexity and controversy surrounding clinical (patient-based), osteological, imaging,
the identification, classification, and etiology of and anatomical research topics. Refer also to
many bone diseases, as well as the vast array of paleopathology bibiliographies compiled by
information that is available in the literature. Crain (1971) and by Elerich and Tyson (1997).
It is hoped that the experiences of the authors While some of these texts may seem outdated,
will make it possible for anyone with a sound they continue to serve the scientific and medical
knowledge of human osteology and skeletal mor- community as some of the most relevant and
phology to conduct a basic descriptive paleo - useable texts in circulation to date. It is hoped that
pathological analysis of one or many skeletons. It the Regional Atlas will serve as a valuable com-
should be noted, however, that the field of paleo- panion to the existing paleopathology literature.
pathology is filled with ambiguities and subtleties. The illustrations in this atlas are predominately
Committing this atlas to memory doesn’t make specimens from the National Museum of Natural
one a paleopathologist; only knowledge, training History (Smithsonian Institution), the National
and, above all, experience will qualify you for Museum of Health and Medicine (Armed Forces
such a title. The Regional Atlas will, however, Institute of Pathology), Washington, D.C., Khon
enable you to conduct your own analysis and, in Kaen University, Thailand, Mütter Museum of
questionable cases, alert you to seek the advice the College of Physicians of Philadelphia and the
of an experienced paleopathologist, radiologist, University of Pennsylvania Museum of Archae-
orthopaedist, or other specialist. The importance ology and Anthropology. Catalog numbers of
of a thorough descriptive analysis and utilization the particular specimens are included where
of an accepted vernacular for paleopathology, appropriate. Other specimens not from these
however, cannot be overemphasized. particular institutions are indicated as to their
To use the Regional Atlas, first become familiar origin. To avoid continuous lengthy location and
with what and where lesions, conditions, and collection’s names, the abbreviations below will
anomalies might be expected in the skeleton, be used for many of the specimens:
locate and identify them in the text, and then refer
to the excellent paleopathology, developmental AFIP National Museum of Health and
and clinical texts by Allison and Gerszten (1982), Medicine, Armed Forces Institute
Aufderheide and Rodriguez-Martin (1998), Barnes of Pathology, Washington, D.C.
(1994), Beighton (1978), Brothwell and Sandison CSC CIL Study Collection, JPAC
(1967), Cockburn and Cockburn (1980), Currey CUJ Chiba University Japan
(2006), Dieppe et al. (1986), Greenfield (1975), FSA Forensic Science Academy
Hauser and DeStefano (1989), Jarcho (1966), KKU Khon Kaen University,
Keats (1988), Manchester (1983), McCarty (1989), Khon Kaen, Thailand
Morse (1969), Moskowitz et al. (1984), Ortner MM Mütter Museum
(2003), Ortner and Aufderheide (1991), Ortner NMNH National Museum of Natural
and Putschar (1981, 1985, 1988), Ortner (2002, History, Smithsonian Insitution,
2003, 2008), Pinhasi and Mays (2008), Resnick Washington, D.C.
(2002), Resnick and Niwayama (1981, 1988), NMNH-H George Huntington Collection
Robbins (1968), Rogers and Waldron (1995), NMNH-T Robert J. Terry Collection
Steinbock (1976), Thijn and Steensma (1990), UHWO University of Hawaii, West Oahu
Tyson and Dyer (1980), Waldron (2008), Webb UPENN University of Pennsylvania
(1995), Wells (1964), Zimmerman and Kelley UTK University of Tennessee (Knoxville),
(1982), or other references in the text, especially Forensic Anthropology Center,
the Journal of Bone and Joint Surgery that deals William M. Bass Collection
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