(2012) Trauma

20 1 Trauma PR O Margaret A. Judd and Rebecca Redfern O F CHAPTER CHAPTER D INTRODUCTION U N C O R R EC TE “World wide, five million people died as a result of an injury in 2000 … for each injury death, there are several thousand injury survivors who are left with permanent disabling sequelae” (Peden et al. 2002:2–3). Unlike other disease processes, such as chronic infectious disease, osteoarthritis and neoplasms, injuries are characteristically immediate due to a sudden unexpected event, although current clinical theorizing views most injuries as preventable (Peden et al. 2002). In antiquity, the injury mechanism was comprehensible. For example, Hippocrates observed in On injuries to the head (Section 11.3–4) “he who falls from a very high place upon a very hard and blunt object is in most danger of sustaining a fracture and contusion of the bone, and of having it depressed from its natural position.” In contrast, the etiology of other diseases was often attributed to supernatural intervention or inexplicable, although superstition pervades explanations for trauma in some modern cultures (Blum et al. 2009). No matter how injury is perceived, the person’s life may come to an abrupt end or their quality of life may be drastically altered temporarily or forever (Oakley 2007). In this chapter we: 1) present and discuss how trauma is defined and classified by paleopathologists; 2) provide an overview of how the study of trauma has changed over time; 3) discuss how the field of paleopathology currently undertakes trauma studies, and 4) conclude with recommendations for future consideration. WHAT IS TRAUMA? Numerous controversies influence our study of ancient trauma, first and foremost being how trauma is defined and classified and secondly, what lesions and pathological changes are considered to be of traumatic origin, which often diverges with A Companion to Paleopathology, First Edition. Edited by Anne L. Grauer. © 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd. Grauer_c20.indd 359 7/7/2011 2:48:12 AM 360 MARGARET A. JUDD AND REBECCA REDFERN U N C O R R EC TE D PR O O F current clinical and social science research (Kirmayer et al. 2008). It is suggested that these controversies in part stem from the researcher’s background and training (archaeological vs. clinical), and the location and type of material they are most familiar with studying (e.g., Europe vs. the Americas, skeletal vs. mummified human remains). These controversies directly affect the presentation and interpretation of results, and therefore our shared past. In the clinical literature, trauma is defined as “a physical wound or injury, such as a fracture or blow” (Oxford Medical Dictionary 2000:670). The International Classification of Disease published by World Health Organization (Peden et al. 2002) classifies injuries as intentional and unintentional and defines injury as being “caused by acute exposure to physical agents such as mechanical energy, heat, electricity, chemicals, and ionizing radiation in amounts that exceed the threshold of physiological tolerance. In some cases (for example, drowning and frostbite) injuries result from the sudden lack of essential agents such as oxygen or heat” (Baker et al. 1984:1). The absence of soft tissue (in most cases) has shaped our conception of paleotrauma, although there is little consistency. Ortner (2003:120) does not define trauma in his introduction, but instead states four ways in which trauma can affect the skeleton: a partial or incomplete break in a bone; abnormal displacement or dislocation of joints; disruption in nerve and/or blood supply, and artificially induced abnormal shape or contour of bone. In her review of trauma analysis in paleopathology, Lovell (1997:139) provides an uncited definition, “trauma may be defined many ways but conventionally is understood to refer to an injury to living tissue that is caused by a force or mechanism extrinsic to the body.” Roberts (1991; 2006; Roberts and Manchester 1995; 2005) has consistently provided a definition reflecting her clinical training – “trauma can be defined as any bodily injury or wound” (Roberts and Manchester 2005:84). Currently, there is no agreement on what paleotrauma includes and how it should be recorded. This may be because, as Ortner (2003:177) observed, “the variants of trauma … affect the skeleton in so many ways that a comprehensive review would fill the pages of a substantial book.” A review of widely used textbooks shows that considerable variation exists in what conditions are regarded as having a traumatic origin or association, reflecting both changes within the discipline as a whole and the development of forensic anthropology. Steinbock (1976) grouped lesions into five general categories: fractures, crushing injuries, sharp-force injuries, dislocations and Harris lines. Brothwell (1981:119) under the assumption that “there would have been relatively few accidents in early times … and most injuries probably resulted from intentional blows,” classified trauma by the pattern produced by weapons (gross crushing, less extensive fracturing, piercing and cutting), but was one of the few to include blood-stained bones, dental evulsion and trepanation. Ubelaker’s (1989) pathological section included fractures (traumatic and pathological), projectile injuries and dislocations. Merbs (1989) discussed fractures, spondylolysis, dental trauma, weapon wounds, dislocations, scalping, surgery, and modification marks (i.e., cut-marks). In Cox and Mays’ (2006) edited volume, the chapters by Roberts (2006) and Boylston (2006) included fractures (traumatic and pathological), amputation, trepanation and weapon injuries, but in contrast to other publications, parturition was considered separately (Cox 2006). In Skeleton Keys, Schwartz (2007:346) noted that “The term Grauer_c20.indd 360 7/7/2011 2:48:13 AM TRAUMA 361 U N C O R R EC TE D PR O O F ‘trauma’ has been extended to incorporate the results of surgery-like or other bodyaltering behaviors,” and cites dental modification/mutilation, foot binding and cranial deformation as examples. Bennike’s (2008) overview of trauma grouped fractures, weapon injuries, spondylolysis, dislocations and trepanation. Mays (2010) included myositis ossificans traumatica, dislocations, and scalping but focused on fractures (traumatic and pathological) and sharp-force weapon injuries. Lovell (1997) classified injuries as fractures or dislocations only, with fractures including knife and sword cuts, scalping, projectile points and crushing due to binding. Lovell’s (2008) revised scheme included myositis ossificans traumatica and placed bones modified by binding as a separate category, but did not discuss sharp-force or projectile injuries. In volumes dedicated to paleopathology, these differences persist. Ortner and Putscher (1981) listed fractures, dislocations, deformations, scalping, mutilations, trephinations, traumatic problems arising from pregnancy, and sincipital T-mutilation in their chapter on trauma. Roberts and Manchester (1995; 2005) added myositis ossificans traumatica, spondylolysis and osteochondritis dissecans, as well as groups of injuries (decapitation, domestic violence, infanticide, child abuse, defleshing and cannibalism); amputation and trepanation were subclassified as treatment. Aufderheide and Rodríguez-Martín (1998) more closely reflected the clinical range of trauma with the addition of localized subperiosteal thickenings, strangulation, cauterization, bloodletting and crucifixion, soft-tissue injuries inflicted by others (laceration, stab, and sacrifice victims), accident due to crushing, asphyxia and burn, and finally mutilation. From a paleoradiological perspective, Chhem et al. (2008) limited bone trauma to fracture, an embedded foreign object, trepanation, heteroptopic bone formation and amputation; joint trauma consisted of dislocation, subluxation and diastasis (separation of the fibrocartilage joint). Finally, Mann and Murphy (1990) in their Regional Atlas of Bone Disease, designated fractures, Schmorl’s nodes and myositis ossificans traumatica as traumatic, while scapular dislocations, trepanation and cranial cut marks were treated separately. Because physical trauma can result from accidents and intentional acts of violence, caution should be paid to what skeletal changes are used to investigate or support certain hypotheses in archaeological populations since we lack the essential resource available to clinicians—the ability to interview a patient and accurately produce a timeline for these pathologies. For example, Tomoya et al. (2001) reported that a 26-year-old woman who was employed as a golf caddie, presented with myositis ossificans traumatica anteriorly to the right hip joint. The woman had no medical or sport history of the injury, but the clinicians concluded that it had developed because cervix stress was frequently applied in the hip. It is evident that there is little agreement among paleopathologists about how trauma is defined, classified and by extension what is recorded, thereby narrowing the comparability between analyses. This arises from both how the term trauma is defined and understood, because if the meaning of trauma is applied in its widest sense, including the hard-tissue repercussions of emotional or environmental events (e.g., famine), it reflects the ethos of the bioarchaeological approach (Buikstra 1977), in contrast to the paleopathological approach that embraces the disease process. Consequentially, rather than attempting to generate yet another trauma classification system, the International Classification of Diseases (World Grauer_c20.indd 361 7/7/2011 2:48:13 AM 362 MARGARET A. JUDD AND REBECCA REDFERN Health Organization 2007) could be considered as a model from which to structure future classifications of trauma. OVERVIEW OF PAST PALEOTRAUMA RESEARCH U N C O R R EC TE D PR O O F From the broader perspective that includes surgical intervention and cultural modification, ancient trepanation and cranial shaping were at the forefront of interest. Paul Broca’s (1867) identification of trepanation on an Incan skull, though not the first account (Aufderheide and Rodríguez-Martín 1998), initiated a worldwide scramble to collect other ancient examples, but more importantly provided the underpinning for the theoretical discourse that followed and continues today (Lucas-Championnière 1878; Arnott et al. 2003). When we adhere to the clinical meaning that equates trauma with injury, anecdotal injuries were increasingly noted by 19th-century anatomists and physicians during their unrolling of Egyptian mummies or in craniometric studies (Pettigrew 1834; Morton 1839). More extensive descriptions were linked with archaeological expeditions. For example, Fouquet’s (1896) paleopathological catalogue recorded injuries among 11 skeletons from El-Amrah, Egypt and compared the injury frequency to other Egyptian collections, thus foreshadowing the 20th-century epidemiological approach to paleopathology. According to Armelagos (2003) and Ortner (2003) a landmark event for paleotrauma, and paleopathology in general, was the Archaeological Survey of Nubia in Egypt and Sudan beginning in 1907. Anatomists observed thousands of individuals and recorded macroscopic pathological lesions, notably injuries. This culminated in a single volume on human remains (Smith and Jones 1910), with an entire chapter devoted to fractures and dislocations (Jones 1910). Jones (1910:294) drew on his medical training to use clinical epidemiology as a means of interpreting the role of the environment and technology in his modal distribution of fractures. He (1910:297) emphasized the importance of the ubiquitous distal ulna fracture and credited Grafton Elliot Smith with attributing it to “fending a blow aimed at the head of the recipient” with the modern Nubian fighting stick the likely weapon; here, Jones made an early reference to gendered violence although unlike the stick-fighting activity he did not actually observe (or at least did not record) any violence against the local females. Fractures were differentiated as being antemortem or perimortem, and made by a blunt or sharp instrument. Of import was a stab wound between two ribs of a mummified individual (Jones 1910:334)—an early observation that fatal (or nonfatal) injury need not affect the bone. Evidence for mass execution and punishment at Shellal (Jones 1908; 1910:100–101, 334–336) included the in situ scraps of textile around the neck and/or wrists in addition to perimortem trauma. Finally, in an early reference to injury recidivism, Jones (1910:336) observed that several individuals had accumulated numerous healed injuries and proposed that these men were either soldiers or members of a tribe at war. Hooton’s (1930) epidemiological approach ushered in a new era for paleopathology (Armelagos 2003; Ortner 2003). Through quantification and fracture frequencies he inferred that earlier and later residents at Pecos Pueblo were more prone to intergroup violence (Hooton 1930:315). While Hooton addressed demographic Grauer_c20.indd 362 7/7/2011 2:48:13 AM TRAUMA 363 R EC TE D PR O O F variables within a group, the problem of differential preservation persisted. Lovejoy and Heiple (1981) tackled this issue and included only complete long bones and crania in their fracture analysis of Ohio’s Libben people. They calculated an elemental fracture rate (total fractured bones/total bones observed × 100 %), and drawing on Buhr and Cooke’s (1959) clinical model they determined that individuals were at greatest injury risk at 10–25 and 45+ years of age, thus introducing aspects of the lifecourse into our understanding of injury. Lovejoy and Heiple’s (1981) systematic fracture recording integrated with comparative clinical studies advocated by Jones’s (1910) and the epidemiological approach of Hooton (1930) advanced our ability to more confidently assess injury patterns and treatment within a society, between contemporary communities and over time. Notably, Grauer and Roberts (1996) concluded that similar fracture frequencies among British urban communities placed residents at common injury risks, while the lack of healing deformity as determined from clinical data revealed that treatment was available to the poorest of individuals and was not restricted to those of high status. Similar approaches to trauma analysis have provided insight into a diverse range of social issues and the consequences of technological developments, such as power struggles (Andrushko et al. 2005), military strategies (Šlaus et al. 2010), ecological decline (Walker 1989; Torres-Rouff and Junqueira 2006), fertility rituals (Conlee 2007), peaceful and volatile imperial administrations (Buzon and Richman 2007; Erfan et al. 2009), hazardous occupations (Djuric´ et al. 2006; Van der Merwe et al. 2010), subsistence change (Domett and Tayles 2006), architectural sophistication (Kilgore et al. 1997) and surgical skill (Mitchell 2006; Redfern 2010). A particularly innovative analysis was that of Berger and Trinkhaus (1995), who proposed that close contact with big game animals was responsible for Neanderthal trauma owing to parallels with injuries sustained by modern rodeo performers. O R OUR CURRENT UNDERSTANDING U N C Since the 1990s, our ability to revisit samples of human remains has undergone a change in response to changes in laws governing the repatriation and retention of human remains (e.g., Fforde et al. 2002; Ousley et al. 2006). Therefore, it is imperative that data is collected in a manner that allows it to be of use to future researchers. Our ability to “move with the times” and revise interpretations has resulted in increased efforts to improve the diagnosis and recording of different types of trauma, particularly for fractures and weapon injuries, in a range of archaeological periods and populations (Maat and Mastwijk 2000; Glencross and Stuart-Macadam 2001; Knüsel 2005; Lewis 2008; and many others). Perhaps the most popularized example is the ongoing re-examination of King Tutankhamun’s mummy in response to new medical technologies (e.g., Hawass 2005; Hawass, et al. 2010). Recording trauma Guidance on how to record trauma can be found in method documents, such as Buikstra and Ubelaker (1994), Brickley and McKinley (2004) and standards designed Grauer_c20.indd 363 7/7/2011 2:48:13 AM 364 MARGARET A. JUDD AND REBECCA REDFERN U N C O R R EC TE D PR O O F for the Global History of Health Project (Steckel et al. 2002), all of which were designed to promote standardization. Other work has focused on how fractures in particular should be recorded. Roberts (2006) and various colleagues (Roberts and Manchester 2005; Grauer and Roberts 1996) provide guidelines on what features and measurements should be documented in macroscopic and radiographic analyses. However, because of differences in funerary treatment, bone preservation and access to imaging facilities, researchers are often unable to fulfill these directions (Prokopec and Halman 1999, 2009, 2010; Redfern 2010). Roberts (2006:347) strongly emphasizes that the bone segment affected must be recorded to provide more detailed information on how the fracture was sustained and also to provide a true prevalence rate calculation. Buikstra and Ubelaker (1994:112–113) enforce the recording of pathology by segment, but little research has been undertaken on how the segment affected is determined, and how that influences data collection and interpretation (Judd 2002a). By correctly locating the fracture to the segment or joint affected and identifying its type (such as transverse, oblique or crush (e.g., Lovell 1997)), our ability to understand how the injury was sustained directly affects how we interpret the injury context and prevalence. The “parry” fracture is a case in point, as reviewed by Judd (2008) and discussed by others, for example, Smith (1996), Alvrus (1999), and Jurmain (2005): parry fractures typically result from a direct blow to the ulna when the arm is raised to shield the face and therefore have been used as indicators of interpersonal violence among past peoples. A more rigorous analysis using the parry signature gleaned from clinical work (transverse fracture on the distal ulna with no radial involvement and minimal unalignment) (Judd 2008) and radiography, aids in differentiating between injuries due to direct force from those obtained by an indirect force, thus facilitating our interpretation of social relations in past societies. Jurmain et al.’s (2009) re-evaluation of a prehistoric skeletal collection from California Bay found that only one of six fractures previously identified as parry trauma met with the criteria, thus greatly reducing the parry fracture frequency and purported victims of interpersonal violence. They concluded that the parry fracture was the least reliable indicator of interpersonal violence and promoted the use of multiple skeletal indicators to infer interpersonal violence. Focusing on a few key paleoimaging developments, the introduction of portable digital radiography equipment revolutionized our ability to study mummified and skeletalized remains, which for various reasons cannot be removed from their curating institution (e.g., St. Bride’s Church, London) or country of excavation (e.g., Egypt, Greece, Syria). This technology requires less training than traditional film radiography, it allows for more images to be taken in a shorter amount of time (Roberts 2010), and because it is a digital resource the acquired images can be more easily archived and disseminated via the internet. Developments in CT and MRI scanning have also improved our diagnostic accuracy in mummified remains, as the acquired images are clearer and can be stored in a digital format. Both forms of imaging produce 2-D cross-sections of tissue and 3-D reconstructions, which better clarifies the state of bone healing and the determination of weapon trajectory. The use of Alicona (2010) 3-D InfiniteFocus imaging microscopes promotes a greater understanding of traumatic injuries, particularly those inflicted by an instrument, because it allows for the creation of a 3-D image that can be quantified, facilitating better comparison to weapon profiles (e.g., Bello and Soligo 2008). Grauer_c20.indd 364 7/7/2011 2:48:13 AM TRAUMA 365 Accidental vs. intentional injury U N C O R R EC TE D PR O O F Determining if a lesion was the product of accidental or intentional violence is reliant on identifying the causative instrument and/or injury mechanism, and integrating contextual evidence (Jurmain 2005:186–188). Some types of trauma, such as sharpforce weapon injuries have a more secure foundation for concluding that they were the result of intentional violence and are clearly differentiated from blunt-force trauma (Jurmain et al. 2009; Jurmain 2005:214–215). For example, injuries sustained by many individuals during the medieval Battles of Towton (England) and Wisby (Sweden) were irrefutably due to sharp weapons (Inglemark 1939; Novak 2000), although it should be noted that sharp-weapons can also produce bone fractures (Knüsel 2005; Novak 2000). However, for fractures it is not such a clear-cut situation. Clinical and forensic literature informs us that we must be cautious in interpreting these data and be aware that many fractures can be caused by an intentional action or accident (Berryman and Haun 1996; Greer and Williams 1999). Moreover, injuries commonly associated with accident, for example those resulting from a fall on an outstretched hand or from a height (Osifo et al. 2010), may be the consequence of an intentional push. In paleotrauma analysis we simply have no way of knowing the ultimate injury mechanism (Judd 2008). It would seem intuitive that the presence of an embedded foreign object is an unambiguous indicator of intentional violence, but we cannot overlook accident. For example, injuries obtained while cleaning weapons, hunting, or handling weapons by inexperienced individuals are regular occurrences in modern emergency rooms (Krukemeyer et al. 2006). Similarly, injuries involving sharp objects used during domestic or occupational tasks may also produce sharp-force trauma (Hang et al. 2005). While some researchers argue that the direct evidence of an embedded weapon is the only reliable evidence of warfare and proximity of artifacts circumstantial (Jurmain 2005; Jurmain et al. 2009), others counter that we should not expect to see associated weapons, as the fundamental function of the weapon is to maim the essential soft tissue organs rather than hit the bone, and perhaps one of the protagonists removes the offending weapon after the deed is committed (Schulting 2006). Forensic and archaeological experiments have shown just this: the majority of lesions inflicted with a projectile or other sharp weapon, such as an arrow, knife, screwdriver or even gun do not touch the bone (Croft and Ferllini 2007; Smith et al. 2007; Letourneux and Petillon 2008). Furthermore, clinical studies report that the majority of assault injuries are soft tissue lacerations, abrasions, cuts and bruising, while broken bones account for 30 percent or less of the total injuries (Shepherd et al. 1990; Brink et al. 1998). Therefore, weapon-oriented trauma and nonintentional trauma, whether fatal or not, is appreciably underestimated in paleotrauma analysis. Paleopathology has sought to provide its own methodologies in the absence or limited availability of clinical data, for example, the identification of sharp-force weapon trauma made by instruments no longer in use (Smith et al. 2007; Letourneux and Petillon 2008). The development of forensic anthropology has allowed its techniques to be employed on archaeologically derived material, which has dramatically improved our ability to recognize and classify blunt and sharp-force injuries (Berryman and Haun 1996; Novak 2000; Lewis 2008). This development is important in archaeological periods or locations where weaponry may be absent or recovered in Grauer_c20.indd 365 7/7/2011 2:48:13 AM 366 MARGARET A. JUDD AND REBECCA REDFERN low numbers (Armit et al. 2007; Redfern 2009). Differentiating perimortem injuries from postmortem damage remains problematic, but ongoing experimentation continues to hone differences (Barbian and Sledzik 2008; Wheatley 2008;) thus negating inaccurate claims of violence, such as the alleged punctures observed in the Taung skull which were later identified as evidence of bird predation (Berger 2006). F Social and cultural meaning U N C O R R EC TE D PR O O Paleopathology has increasingly drawn on social science theory, such as feminist (Gilchrist 1999), gender (Gero and Conkey 1995), and age (Sofaer Derevenski 2000), in order to provide more nuanced interpretations. More recently, newer theoretical concepts built on these foundations have given rise to frameworks concerned with identity (Insoll 2007), lifecourse (Hutchinson 2008) and personhood (Fowler 2004). These shifts have greatly enhanced researchers’ analyses of individual case-studies (Knüsel 2002) as well as larger samples (Stirland 2001), and prompted those working with ancient people to not only critique their application to human remains (e.g., Geller 2005), but also to develop theoretical frameworks specific to human remains. Two significant approaches have come to the fore: the osteobiography approach advanced by Saul (1972; Saul and Saul 1989) and cultivated by Robb (1997; 2002), and that promoted by Sofaer (2006), which attempts to analyze the body in a “material culture” approach. Saul and Saul (1989) encapsulate the osteobiographical approach by posing four questions of the individual or sample under consideration: (1) Who was there? (2) Where did they come from? (3) What happened to them? and (4) What can be said about their way of life? Extending from this is the narrative biography or experienced cultural osteology employed by Robb (2002) to provide new insights into the individual lives, community as a whole and mortuary treatment. Sofaer (2006) identified the academic division between the dead and living body as a false separation of analysis and interpretation (e.g., exemplified in the appended display and discussion of osteological data in site reports), and argued that this arbitrary disconnection does not reflect the true relationship between a person’s life, body and underlying skeleton. At first glance, this statement appears self-evident, particularly to paleopathologists. However, we frequently forget that the individuals we study did not have a homogeneous or static life from birth to death. Our greater understanding of skeletal remodeling over the short and long-term (Shaw and Stock 2009) and the interrelationships between immunity, health, culture, environment and society (e.g., Schell 1997; DeWitte 2010) make it very evident that individual lives are shaped by their biological sex, socio-economic status within the community, occupations performed and the environment in which they lived (Molnar 2006; Buzon and Richman 2007). These forces will result in modifications to the underlying skeleton, many of which we can observe, and should not be neglected by trauma studies. For example, young males who died during episodes of warfare or were considered to be warriors may have been interred with this status clearly signified in the burial record (Treherne 1995; Sarauw 2007). However, anthropological studies of the life course reveal that warriorhood may be a transitory stage (Foner and Kertzer 1978; Thomas 1995). Foner and Kertzer (1978:1085) reported that in the Kipsigis tribe of Kenya, the post-infancy male lifecourse is divided into boyhood, warriorhood, and elderhood, with the warrior stage having the highest prestige and personal Grauer_c20.indd 366 7/7/2011 2:48:13 AM TRAUMA 367 U N C O R R EC TE D PR O O F freedom. Consequentially, survivors who enter other adult status groups may be buried without reference to this previous identity (Sayer 2010). Trauma studies of interpersonal violence have increased in recent years (Park et al. 2009), perhaps in response to escalating levels of violence in our own communities, motivating paleopathologists to consider this behavior among past peoples, particularly against women and children ( Smith 1996; Walker 1997; Walker et al. 1997). Child abuse is especially problematic as most children survive abusive injuries or the ensuing death is not detectible from the skeletal remains, although cases for abuse have been proposed by Blondiaux et al. (2002) in France and by Wheeler et al. (2007) in Egypt. If we look to clinical research for guidance, clinicians have been unsuccessful in their quest for skeletal abuse indicators among adults, although soft tissue facial injuries are profuse (Allen et al. 2007; Brink 2009). We tend to assume that domestic violence was perpetrated by males, when in fact cultural anthropologists observe that active female participation is widespread particularly in same-sex relationships (McClennen 2005) or in polygynous societies, where altercations among co-wives are regarded as unimportant “nonevents” (Burbank 1994). Active female participation in violent acts towards men, children and other women is rarely deliberated by paleopathologists despite a growing body of bioarchaeological research (Guliaev 2003) and mounting contemporary findings (Mechem et al. 1999; Hirschinger et al. 2003). Ethnographic sources not only provide alternatives to consider in our interpretations of trauma but inform the legitimacy of violence within gender and power hierarchies. For example, among the indigenous residents of Mangrove (Australia) fights are mundane occurrences sanctioned by specific rules as to who one does not fight (mothers-in-law, opposite-sex sibling) and which bodily regions (hands, arms, legs) are acceptable to hit with one’s fighting stick (Burbank 1994). A paleopathologist studying skeletal remains from this community might therefore attribute the lack of cranial and sharp-force trauma to environmental hazards and accident rather than widespread socially sanctioned interpersonal violence among adults. More importantly, this example illustrates that what we consider to be abusive or deviant behavior is acceptable and expected by contemporary societies elsewhere. As a discipline we sometimes fail to appreciate that violence is extraordinarily meaningful to the construction and maintenance of identity, gender, age and status (Singer 2006; Sen 2007; Terrell et al. 2008; Graves 2010), and was used by many past populations in religious ceremonies and to enforce social and economic inequalities (Verano 2005; Chacon and Dye 2008). Therefore, we should also be aware of the discrepancy between the meaning of violent acts and the often unpleasant nature of evidence itself. For example, during the Inca Empire children were sacrificed to the Gods, either killed by a blow to the head, strangled or asphyxiated during capacocha ceremonies. These children were regarded as messengers or representatives of their communities to the gods, and selection was considered to be a great honor; notably, they were not subject to physical deprivation before being sacrificed (Ceruti 2004). Paleopathologists have been guilty of making interpretations based on trauma data collected from human remains without first considering the social and cultural meanings of violence in the community under study. This has impacted greatly on how individuals or samples are interpreted within paleopathology (see Jurmain 2005:227–229), but also how these interpretations are perpetuated within the anthropological literature. For example, Chadwick-Hawkes and Wells (1975) asserted that Grauer_c20.indd 367 7/7/2011 2:48:13 AM 368 MARGARET A. JUDD AND REBECCA REDFERN PR O O F ossified muscle traumas identified on the femora of a young Anglo-Saxon female were the result of a violent rape. This interpretation was incorporated into the wider literature and was not critiqued or questioned until Andrew Reynolds (1988) and later Nicholas Reynolds (2009) demonstrated that this was a classic case of overinterpretation. Nevertheless, the false assertion continues to be included in research (e.g., Arnold 1997). A more famous case is that of Özti the Iceman, an ice-mummy recovered from a glacier at the Italian–Austrian alpine border in 1991, who dates to the Chalcolithic period (3350–3300 B.C.). While the mummy displays evidence of participating in hand-to-hand combat shortly before death, and has an embedded arrow injury in the back, numerous scientists, using trauma and other data, have attempted to reconstruct his identity and the manner and cause of his death; interpretations have ranged from participation in organized violence, human sacrifice and murder, but now the consensus is that he died whilst fleeing from danger (EURAC 2010; Pernter et al. 2007; Nerlich et al. 2009). Body modification as trauma U N C O R R EC TE D As indicated above, not all scholars regard evidence for body modification in life and death as trauma. This may be because some researchers recognize the wider meanings associated with these acts that may not be considered as violent, such as in the construction of gender and status among Italian Iron Age communities (Robb 1997), the maintenance of ethnic identities in periods of sociocultural change through lip piercings and head shaping in the Late Intermediate Period of Chile (e.g., Knudson and Torres-Rouff 2009; Torres-Rouff 2009), or the recognition that the human body can be used to transcend individual identities for wider community purposes, such as traditional Buddhist practices in Tibet which transform human remains into ritual objects (e.g., flutes or bowls) (Malville 2005). Cannibalism epitomizes these differences in approach, as this practice is used as a survival mechanism, to subjugate enemies, and a stage in funerary practices (amongst others, Keenleyside et al. 1997; Degusta 1999; Billman et al. 2000; Beaver 2002; Gottlieb 2007; Lindenbaum 2009). The skeletal markers of cannibalism are similar cross-culturally and temporally (White 1992; Turner and Turner 1998), therefore it is interesting to observe how differently these markers can be presented, interpreted and judged as evidence of the practice (Billman, et al. 2000; Dongoske et al. 2000). It should also be noted that the vast majority of evidence for body modification is presented and discussed as case studies (McNeill 2005), and only in recent years have attempts been made to understand the evidence in its regional, cultural and historical context (Chacon and Mendoza 2007; Torres-Rouff 2009). Limitations One hundred years have passed since Smith and Jones’s 1910 landmark trauma report and we still struggle with many of the same difficulties specific to trauma that challenged these pioneering paleopathologists. Taphonomy can obscure, mimic or obliterate bone, particularly perimortem trauma where the freshness of the lesion is attractive to scavengers (Lotan 2000; Denys 2002; Berger 2006; Wheatley 2008). We do not know the age at which the fracture occurred and therefore the susceptibility of Grauer_c20.indd 368 7/7/2011 2:48:13 AM TRAUMA 369 O R R EC TE D PR O O F one age-group to injury cannot be determined unless the fracture was in the process of healing or perimortem (Maat and Huls 2009). The contemporaneity of multiple antemortem injuries is also problematic, although a case for injury recidivism has been argued by Judd (2002b). There is scant evidence for subadult trauma in the paleopathological record (Lewis 2007), although it may be that the reparative resilience of the child’s bones masked earlier injuries or that the child survived and entered the sample as an adult. We must also consider that the majority of ancient injuries and accidental fatalities will be undetectable even in the most pristinely preserved skeletons if only soft tissue was involved or as in modern developed and developing nations, the most fatal injuries affecting subadults, such as drowning, burns, fatal stings and poison ingestion, leave no skeletal traces (Baker et al. 1984). It is often assumed that individuals with violence-related injuries were passive victims. For example, the widely cited site of Jebel Sahaba in Sudan (Wendorf 1968), as being the earliest evidence for warfare based on some embedded flakes and multiple burials, is presented by researchers, such as Guilaine and Zammit (2005), as a community massacre even though there is no archaeological evidence that these people were helpless victims. If there were an attack or series of attacks, it may well be that the alleged victims were the initiators of a blood-feud or retaliation. This problematic assignment of “victim” and “assailant” has been dealt with in clinical settings, where injured individuals are nonjudgmentally referred to as “participants” (Shepherd et al. 1990). While clinical and ethnographic research provides a wealth of information from which to draw interferences and structure hypotheses, it is similarly problematic. The clinical classification of physical trauma is subject to ongoing alterations, because of advances in medical science, the revision of outdated nomenclature, and technological changes in warfare and daily-life, for example, the use of radiographs from 1895 and the introduction of automatic weapons. Clinicians disagree on the origins of minor traumas that also perplex paleopathologists, notably dental avulsion, Harris lines, osteochondritis dissecans, spondylolysis, Schmorl’s nodes and myositis ossificans traumatica (Siffert and Katz 1983; Schenck and Goodnight 1996; Bastone et al. 2000; Battie, et al. 2008). Finally, not all injuries or abuse cases are reported or are attended to as a result of proximity, lack of documentation of patient, expense, social inaccessibility, fear or stigma (Mock et al. 1995; Nordberg 1994). U N C FUTURE CONSIDERATIONS When considering future directions for paleotrauma research we suggest three key areas: the inclusion of minor trauma; the association between disability, other diseases and injury patterns and prevalence; and the social consequences of traumatic injury. Minor traumas, such as injuries to the dentition, extremities and flat bones of the torso (scapulae, ribs, manubrium and sternum) are often neglected by trauma studies, which predominantly focus on cranial or long-bone injuries. We recognize that such trends are influenced by factors such as funerary strategies, recovery methods employed during excavations and preservation, but clinical studies emphasize the importance of injury patterning to these areas to determine interpersonal violence, accidental or intentional falls, and occupational injury. A small number of studies have shown that important sociocultural inferences can be made from the Grauer_c20.indd 369 7/7/2011 2:48:13 AM 370 MARGARET A. JUDD AND REBECCA REDFERN N C O R R EC TE D PR O O F study of these injuries (e.g., Brickley and Smith 2006). Dental injuries are noticeably absent (Jurmain 2005; Lovell 2008), although they are sometimes included with dental disease (e.g., Ortner, 2003) or occupational modifications (Molnar 2008; Scott and Winn in press). This may be because identification and classification can be problematic and made more troublesome by taphonomic changes (Hinton 1981). Interestingly, the exclusion of dental trauma assessment is not exclusive to paleopathology. Lieger et al. (2009) observed that clinicians rarely differentiate between maxillary or mandibular injuries, and therefore, the true prevalence of dental injury is obscured even in clinical trauma studies. Clinical research shows that the majority of dental injuries are sustained during childhood by falls, play and sports (Bastone et al. 2000; Eyuboglu et al. 2009). In adults, tooth injuries in isolation are in fact seldom pathognonomic of interpersonal violence (Muelleman et al. 1996). Studies such as Holst and Couglan’s (2000) detailed assessment of the medieval Towton soldiers and Lukacs’s (2007) recent work on dental trauma among ancient Canary Islanders underscore the value of integrating contextual information and evidence for other craniofacial trauma when interpreting these and other direct injuries to the face. In many trauma studies data collection and interpretation often fails to display or discuss data in relation to other conditions. For example, consider an older female with a Colles’ fracture (Mays 2000). Is this evidence for a fall or osteoporosis? Inevitably, the role of classification and access to radiography plays a role in these decisions. We have also neglected to address disabilities and their influence and association with patterns of trauma, as most clearly shown in the study of leprosy and fractures by Judd and Roberts (1998), but also how the co-existence of diseases, such as septic arthritis or tuberculosis, can influence the prevalence and pattern of injuries in individuals (Ferrara and Peterson 2000). Finally, the emphasis on the populational approach that advocates the health of the group (e.g., Steckel and Rose 2002) to the detriment of the individual depersonalizes trauma, glossing over the devastating impact of the injury on the individual’s quality of life and emotional well-being (Mays 2006), and that of their family, friends and community. However, several researchers have provided comprehensive osteobiographies to underscore the debilitating effects of trauma on the individual (Hawkey 1998; Neri and Lancellotti 2004; Mays 2006). Others approach society’s response to circumventing more severe impairment through treatment and advances in medical knowledge (Dupras et al. in press; Redfern 2010). U CONCLUSION Grauer_c20.indd 370 Paleopathologists investigating ancient trauma are presented with an individual’s lifetime accumulation of injuries and attempt to explain the injury mechanisms, in addition to the contemporaneity of injuries. As methods of distinguishing and recording ancient injuries increasingly cross forensic, clinical and archaeological boundaries, we might venture to differentiate injury in the clinical and forensic sense, from the broader culturally inclusive meaning of trauma that would include modifications to the body (any tissue) in order to heal, beautify or distinguish. But suppose that we are presented with an individual with a healed amputated forearm? Without documentation and/or other distinguishing funerary features, how do we determine if the 7/7/2011 2:48:13 AM TRAUMA 371 O F amputation was a surgical intervention, an occupational or sports accident, an intentional mutilation received during warfare or a form of punishment with the social debt settled? 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