Since its discovery in 1947, the dating of Fontéchevade I, a fragment of human frontal bone (lacking a supraorbital torus), has posed a problem for paleoanthropologists. In spite of its apparently modern appearance, it has been considered to date from the last interglacial or even earlier. Such a date would be much earlier than any other convincing evidence of anatomically modern peoples in Europe. One goal of the excavations reported in this monograph was to clarify the chronological position of the Fontéchevade I specimen.

Fontéchevade I was recovered approximately 6.5 m in front of the present-day dripline of the cave, in Henri-Martin's Bed E0 – that is to say, 2.40 to 2.60 m below her datum (Henri-Martin 1957). About 2 m farther toward the cave, in Bed E1′ (2.60–2.80 m below datum), a more archaic-looking calotte (Fontéchevade II) was discovered.

Fontéchevade I consists of a fragment of frontal that includes glabella, the medial portion of the left superciliary arch, and a small part of the squamous portion above these. What is remarkable about this piece, given its apparent age, is the complete absence of a frontal torus. This feature, as well as the thinness of the squamous portion, gives it a very modern appearance. Fontéchevade II consists of the upper part of the frontal bone and portions of the left and right parietals. The specimen, much more archaic in appearance, is distinguished by the thickness of the cranial walls.

HISTORICAL BACKGROUND

This chapter describes some of the Upper Paleolithic lithic material recovered from Fontéchevade during the early part of the twentieth century. Upper Paleolithic remains, in varying amounts and from both inside and outside the cave, had been noted by several excavators. The first to uncover these industries was L. Durousseau-Dugontier, between 1902 and 1910, but unfortunately his results were never published and his excavation notes have been lost (Henri-Martin 1957). In 1913 and 1914, M. Vallade undertook more systematic excavations, uncovering three beds of Upper Paleolithic. G. Henri-Martin used Vallade's unpublished results when she published her own excavations (1957). In 1921, M. and Mme. de Saint-Périer opened a trench at the opening of the cave, which yielded some Upper Paleolithic elements (1957). In 1933, P. David (1933) carried out several tests that also produced some Aurignacian artifacts. Although the most significant excavations were carried out starting in 1937 by Henri-Martin, the Upper Paleolithic had already been almost entirely removed, with only two remnants of the Aurignacian bed found (Henri-Martin 1957). In the course of the 1994–1998 excavations, no Upper Paleolithic was found in situ, though several indisputably Upper Paleolithic elements were uncovered in disturbed contexts.

DATA FROM THE OLD EXCAVATIONS

The first excavations by Durousseau-Dugontier produced pottery sherds as well as Typical Aurignacian and Châtelperronian lithics, although it is impossible to know if the excavator recognized any stratigraphy.

EXCAVATION METHODS

What follows is a description of the methods used in the current excavation of Fontéchevade and an overview of the work accomplished. The methodology is based in part on French tradition for Paleolithic excavations and in part on the methodologies that our team has developed through the years at the sites of La Quina, Combe-Capelle Bas, Cagny-l'Epinette, and Cagny-la-Garenne. Much of the methodology is based on the application of computerized recording techniques, which have been extensively described in previous publications (Dibble 1987b; Dibble et al. 1995; Dibble and McPherron 1989; McPherron and Dibble 1987, 2002). Special emphasis was given to standardizing the excavation techniques and recording methods at Fontéchevade, both to optimize analysis of the site itself and to make the data comparable with data collected at the previously listed sites.

The excavation grid

The site was excavated in 1-m units following the traditional French system of labeling excavation units with a letter-number designation. In this system, it is also traditional to place grid north directly into the cave. We followed this tradition, despite the fact that true north is almost exactly 180 degrees opposite. One of the principal advantages of doing so is that all of our maps are thus oriented in relation to the long axis of the cave, very much as we saw the cave each day. The principal disadvantage to this system is that there can be some confusion between, for instance, “west” and “grid west.

There is considerable interest in growth and development, both historical and anthropological. Growth and development is an area to which the study of skeletal assemblages is able to make a significant contribution. Final achieved height is determined to a great extent by genetic factors and by the influence of hormones, most importantly growth hormone and thyroxin, but in populations which share a similar genetic makeup, the state of nutrition during the period of active growth during puberty is the most significant factor. Thus, it is often taken as a surrogate for the comparison of nutritional status in different skeletal assemblages.

NORMAL GROWTH

As is well known, the growth of the skeleton does not proceed in a uniform manner from birth to adulthood, but there are two major linear growth spurts during childhood: the first during the first two years of life, and the second which begins at puberty. From birth to age one, growth proceeds at a rate of between 18–25 cm, and from one to two, at 10–13 cm per year. The pubertal growth spurt, which is generally supposed to be the most rapid, actually proceeds at the rather more stately pace of 6–13 cm per year. It is, however, more prolonged and is the period during which most height is gained. The importance of genetic factors is well illustrated by the fact that tall parents tend to have tall children, and short parents, short children.

The majority of bones in the skeleton first appear in the fetus as cartilage models that calcify and ossify. The exceptions to this are the bones of the cranial vault and the clavicles, the primordal of which are formed by mesenchymal cells. Long bones grow in length at the growth plates situated at the junction of the shaft (diaphysis) and the ends of the bone (the epiphyses). Circumferential growth is achieved by the laying down of bone beneath the periosteum which covers the entire outer surface of all bones except that covered by articular cartilage. Bone is also laid down under the endosteum, which lines the inner surface of the bones. The entire process from cartilage formation, calcification, mineralisation, joint formation and remodelling is controlled by a plethora of genetic and molecular systems which are still by no means completely understood.

TYPES OF BONE

Macroscopically, two types of bone can be distinguished in the skeleton, dense cortical (or compact) bone, such as forms the shaft of the femur and the humerus, for example, and cancellous (or spongy) bone, which occupies inter alia the ends of the long bones and the vertebral bodies. Cancellous bone is formed from trabeculae, bars and plates of bone arranged in a honeycomb manner which convey considerable strength to the region of the bone containing them, but also provides a huge surface area for metabolic reactions.

The joint diseases can be simply divided into those in which the major feature is the proliferation of new bone and those in which the loss of bone is the most striking feature; the latter are collectively known as the erosive arthropathies. A simplified family tree of the joint diseases showing those that are most likely to be found in the skeleton is shown in Figure 4.1.

Osteoarthritis is the archetypal proliferative joint disease but there are many different erosive joint diseases, including an erosive form of OA. However, only a small number of the erosive arthropathies are likely to be encountered during the examination of a skeletal assemblage and it is these that will be discussed here. The most characteristic of the erosive joint diseases is rheumatoid arthritis.

RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is generally considered to have first appeared in the clinical literature in the MD thesis of the French physician Augustin Jacob Landré-Beauvais (1772–1840). The thesis described the clinical findings in a group of nine patients whom Landré-Beauvais attended at the Salpêtrière hospital in Paris. The signs and symptoms differed in a number of ways from those found in other forms of gout, the rubric under which the joint diseases were all included at the time. It was more common in women, involved many joints from the onset and ran a chronic course. Landré-Beauvais was certain that he had discovered a new form of joint disease, which he called primary asthenic gout (goutte asthénique primitive).

BONE FORMING AND BONE FORMERS

Within any skeletal assemblage there seems to be a proportion who apparently had a tendency to ossify soft tissues, especially the entheses, that is, the point at which tendons insert into bone, probably in response to minimal repetitive trauma. The result is the production of bony spurs at these points, which are referred to as enthesophytes. We alluded to these individuals as bone formers but our original definition was later modified by Rogers and her colleagues. Rogers and colleagues examined the sites of a series of entheses in the skeleton (fourteen in total) to see which showed the presence of an enthesophyte. The total number of enthesophytes was then divided by the number of sites examined and if the score was equal to, or greater than 0.3, that was considered evidence of bone forming. Bone formers are probably more likely than others to produce heterotopic ossification and to calcify or ossify costal cartilages, the thyroid cartilage and other soft tissues. It is not certain what proportion of the population are bone formers but it may be up to a fifth. There are several skeletal diseases in which bone forming is a feature – some joint diseases, some infections and Paget's disease, for example – and it is likely that the production of bone in these conditions will be particularly exuberant if the individual is also a bone former.

I entered palaeopathology via a very circuitous route, having previously had a background in anatomy, toxicology and epidemiology, although an interest in pathology was always present, having been greatly stimulated by the subject during my time as a medical student. My first hands-on experience with bones, however, was in collecting specimens for lead analysis when I was working at the University of Birmingham. We undertook the analysis of many hundreds of specimens until it became clear that the variation in lead levels that we were finding owed much more to contamination from the soil than to exposure during life, and I formed the view that it would be more profitable to see what information could be obtained from the bones themselves. When I moved to London to work at the London School of Hygiene and Tropical Medicine (LSHTM), I became very active in examining skeletal assemblages and some mummified material, and I had the good fortune to become acquainted with Don Brothwell at the Institute of Archaeology, which was just a few minutes walk around the corner from the LSHTM. He not only kindly gave me a corner of a desk, but invited me to take part in the teaching of the undergraduates and post-graduates at the Institute. I have had the great pleasure of teaching at the Institute now for many years, and this book is based very largely on the course of lectures in palaeopathology that I give to those taking the master's courses.

Most experts believe that infectious diseases were common in the past and that many of the deaths of the very young seen in skeletal assemblages would have resulted from gastro-intestinal infections, as is the case in developing countries today. Almost all forms of infection spread by the faeco-oral route must have been common in the past and almost unavoidable before there was any way to separate drinking water from sewage. Unfortunately for the palaeopathologist, the infections that are likely to have accounted for the death of children leave no stigmata on the skeleton and until and unless we are able to extract bacterial or viral DNA or RNA from the bones of their victims, we will remain ignorant of if, and how often, infectious diseases might have caused death.

Those living in tropical climates would have almost certainly died from malaria and other tropical infections, probably at no less a rate than at present, while at various times the plague, smallpox and cholera all accounted for terrible, episodic periods of mortality in tropical and non-tropical climes. For most infections to be sustained, a large population is required and so the acute bacterial and viral infections are not likely to have assumed significant threats to life on a large scale before populations became settled and grew in numbers. For the hunter gatherers, and other nomadic peoples, the main burden of infectious diseases would have been from parasites living in the gut, which survive for long periods in their hosts and reproduce asexually in situ or lay eggs that can be picked up from the environment by uninfected hosts.

Teeth generally survive well and provide an important source of information not only about dental disease, but also the use of teeth as tools, and social habits such as artificial deformation. Tooth wear is widely used as means of ageing skeletons. The diseases considered here include dental caries, ante-mortem tooth loss, periodontal disease, dental abscesses, calculus and enamel hypoplasia. A brief account will also be given of dental tumours.

CARIES

Caries is the most common cause of oral pain and tooth loss. It has almost certainly affected humankind from earliest times, although the site of the disease on the tooth has changed in relation to changes in the diet. Briefly, before the introduction of sugar into the diet, caries tended to appear at the cemento-enamel junction, or the appositional surfaces. Once sugar was widely available it affected the fissures on the molars more frequently than elsewhere, and this is the pattern that continues to this day although the widespread fluoridation of drinking water has reduced the prevalence of caries very considerably. Those who can remember how painful caried teeth can be will not be surprised that attempts at treatment have an extremely long history. Fillings have a long usage often involving soft and easily malleable materials such as lead or tin, and amalgam fillings – a solution of one or more metals in mercury – were introduced in the early nineteenth century while nowadays, mercury-free fillings are gaining increasingly in popularity.

Although the word tumour simply means a swelling, in the minds of most people it has unpleasant connotations as it is frequently taken as a synonym for cancer, which it is not. Without any further elaboration, a tumour is simply a new growth and on this account it is sometimes also known as a neoplasm, and the process by which it arises, as neoplasia. Tumours may be classified as either primary or secondary, or as either benign or malignant. A primary tumour is one that originates in the tissue in which it is found, whereas a secondary tumour is one that has arisen in a different tissue from that in which it is found. A benign tumour does not spread beyond the tissue in which it originates. By contrast, the characteristic of a malignant tumour is that it does spread beyond its tissue of origin. Malignant tumours are often a cause of death whereas this is generally not the case with benign tumours, although there are exceptions as we shall see. A secondary tumour is malignant by definition, but a primary tumour may be either benign or malignant.

EPIDEMIOLOGY OF BONE TUMOURS

Primary bone tumours are uncommon and benign tumours are much more common than malignant. Malignant primary tumours of bone account for less than 1% of all malignant tumours and are more common in males than in females except in late childhood when there is a very slight female excess. The male excess becomes increasingly apparent with increasing age.

For the examination of soft tissue diseases, mummies come into their own, subject to the limitations that were mentioned briefly in Chapter 1 and which may need to be expanded upon here. The principal constraint is that, in most parts of the world, mummified remains are greatly in the minority and most palaeopathologists will spend most of their working lives dealing with human remains that have no soft tissue attached to them. There is then the problem that even in those cultures in which mummification, either direct or indirect, was the major means of disposing of their dead, the bodies may often lack the internal organs, and where they are present, it may be difficult to examine them without subjecting the mummy to an autopsy or to endoscopic examination. A full autopsy is – understandably – often not permitted because it is, by its nature, destructive and many archaeologists and museum curators are reluctant to permit valuable exhibits to be partially or completely destroyed. Modern imaging techniques such as CAT or MRI scanning permit non-destructive examination to be made but they are expensive and by no means available to all investigators, and certainly not on a large scale without special funding. Even when available, the results may not always be instructive because of changes in the tissues resulting either from the mummification or from natural decay.

The study of disease in earlier societies stands firmly in the purview of the discipline of the history of medicine. There are a number of ways in which the subject can be approached, such as from the study of extant medical texts or of pictorial or plastic art and artefacts. However, the most direct approach is from the examination of the physical remains of our ancestors. Each approach has its limitations and calls for different skills. The preservation of documentary evidence is subject to random vagaries, at least as great as the preservation of human remains. The medical historians must be able to set their interpretation of the written word in the context of the various theories of disease extant at the time the original was written. Medical historians will also almost certainly need to be proficient in some languages other than their own. Those who attempt to diagnose disease from paintings, pots or sculpture will need to be familiar with the artistic conventions of the artists whose artefacts they study.

Palaeopathologists have the advantage of being able to study directly the remains of the diseased, although usually only in part, and this ability may be the only factor in their favour. The principal disadvantage that constrains palaeopathologists is that their study is restricted largely to those diseases that affect the skeleton – preserved soft tissues being decidedly unusual in most parts of the world.

There are several different types of joint in the skeleton (Table 3.1). The synovial joints are the most numerous and the only ones commonly affected by disease. Some joints change their appearance with age and these changes are often used by physical anthropologists to help age a skeleton. The pubic symphysis and the auricular surface of the ilium are particularly useful in this regard.

The structure of a typical synovial joint is shown in Figure 3.1. In this type of joint the articulating ends of the bone are held in place by a capsule which is composed externally of a layer of fibrous tissue that varies in thickness partly due to the attachment of ligaments of tendons. The inner layer is composed of the synovial membrane. The capsule is well supplied with blood vessels, lymphatics and nerve endings which may extend down to the synovial membrane.

The articulating ends of the bone are covered with cartilage which varies in thickness from 1–7 mm; it is thicker in larger than in small joints and in joints under considerable stress, such as those of the leg. The cartilage is avascular, has no lymph vessels and is not innervated. The cartilage-forming cells (the chondrocytes) obtain their nutrients by diffusion from fluid within the joint. Articular cartilage provides a moveable surface with an extremely low coefficient of friction, much less than that of two opposing Teflon-coated surfaces.

There are a number of diseases that interfere with the normal metabolism of the skeleton. They include osteoporosis, Paget's disease, rickets and osteomalacia, and scurvy. Some conditions in which there is a hormonal imbalance also affect bone and some of these will be considered in this section.

OSTEOPOROSIS

Until early adult life the skeleton is in positive balance, that is to say, a larger amount of bone is formed than is lost and the total skeletal mass increases until it reaches a maximum at about the age of 25–30. The absolute value of the maximum bone mass (MBM) varies from individual to individual and is dependent on a number of factors including sex, activity, diet and race. After the MBM is achieved the skeletal balance is reversed and there is a net loss of bone during the following years. Women lose bone at a faster rate than men at all ages but their rate of loss increases after the menopause when the depressing effect of oestrogen on the osteoclast is lost. Bone is lost more rapidly at some sites than others, and the rate of trabecular bone loss tends to be greater than the rate of cortical bone loss. If the rate of bone loss becomes too great, and particularly if much trabecular bone is lost, the risk of a fracture occurring is considerable, especially of those bones that contain a great deal of trabecular bone, most notably the distal radius, the femoral neck and the vertebrae.