Diarrhoea, Dysentery, and the Clap: Connecting the Military Lifestyle to Literary & Skeletal Evidence of Reactive Arthropathy Induced by Bacterial Infections
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DIARRHOEA, DYSENTERY, AND THE CLAP: CONNECTING THE MILITARY LIFESTYLE TO LITERARY & SKELETAL EVIDENCE OF REACTIVE ARTHROPATHY INDUCED BY BACTERIAL INFECTIONS Meghan E. Banton Thesis submitted for the degree of Doctor of Philosophy UNIVERSITY COLLEGE LONDON Institute of Archaeology [1] DECLARATION I, Meghan E. Banton, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. ABSTRACT Military combatants are frequently exposed to physical exertion, sleep deprivation, deficient diets, and stress, which can all reduce the immune system’s ability to ward off infections. Making matters worse, combatants frequently inhabit overcrowded and unsanitary living conditions, which allow bacteria to thrive. As a result of these circumstances, the military lifestyle is associated with increased exposure and susceptibility to infectious diseases. This explains why epidemics are extremely common during times of war, especially in pre-twentieth century conflicts. Though military infectious diseases have been the topic of much research, bioarchaeological contributions have been limited, as most infectious diseases do not cause direct skeletal changes. For example, diarrhoea, dysentery, gonorrhea, and tonsillitis do not cause skeletal changes, but all are known to have been common among historical combatants. Though direct skeletal changes are not produced, the pathogenic bacteria causing these ailments can trigger reactive arthropathies (arthritic conditions caused by microbial infections), which includes the Spondyloarthropathies. Spondyloarthropathies cause skeletal changes and can be observed in archaeological remains. As such, the present research has chosen to explore the potential consequences of military infectious disease by answering the following question: were reactive arthropathies an occupational hazard to past military combatants? This question is answered through two methods. First, historical research methods were employed to investigate the primary research question and to provide a detailed medical history of the emblematic example of reactive arthropathy, Reactive Arthritis. Secondly, a palaeoepidemiological study was designed and implemented to understand the prevalence of reactive pathology in military skeletal assemblages; this is a novel bioarchaeological means of understanding the potential impact of military infectious diseases. [2] TABLE OF CONTENTS Declaration & Abstract………………………………………………………………..pp.2 Table of Contents……………………………………………………………………...pp.3 List of Illustrations & Tables…………………………………………………………pp.9 Dedication……………………………………………………………………………...pp.15 Preface …………………………………………………………………………………pp.16 Acknowledgments …………………………………………………………………...pp.19 Introduction……………………………………………………………………………pp.21 BACKGROUND CHAPTERS Chapter 1: Clinical Background …………………………………………………………………pp.37 1.1 Reactive Arthropathies: Bacterial Infection & Arthritis ……………………… pp. 38 1.2 Nonreactive Erosive Arthropathies: Erosive Osteoarthritis & Gout…………..pp.43 1.3 A Probable Reactive Arthropathy: Rheumatoid Arthritis………………………pp.48 1.4 Reactive Erosive Arthropathies: The Spondyloarthropathies…………………pp.51 1.4.1 Pathological Expression………………………………………………..pp.51 1.4.2 Bacterial Infections………………………………………………………pp.56 1.4.3 Matters of Classification………………………………………….……. pp.59 1.4.4 The Link to HLA-B27…………………………………………………....pp.60 1.5 SpA as a Measure of 'Reactive' Pathology in Skeletal Material……………...pp.63 1.6 Differential Diagnoses ……………………………………………………………pp.64 1.6.1 Differentiating SpA from other EAs……………………………………pp.64 1.6.1 Differentiating SpA from Non-Erosive Conditions……………………pp.70 [3] Chapter 2: The Military Lifestyle, Infectious Disease, & Rheumatism ............................pp.83 2.1 Historiography & Historical Context….………………………………………….pp.85 2.1.1 Military Medicine & Disease…………………………………………....pp.85 2.1.2 Consideration of Bias ………………………………………..............pp.121 2.2 Military Susceptibility to Infectious Diseases………………….…………...…pp.125 2.3 Military Lifestyle & Bacterial Diseases…………………………………………pp.129 2.3.1 Diseases of Environment: Gastrointestinal & Pharyngeal Infections……………………………………………….…pp.129 2.3.2 Diseases of Behaviour: Venereal Diseases………………………..pp.142 2.4 The Military and Rheumatism…………………………………………………..pp.156 Chapter 3: Research Questions………………………………………………………………..pp.159 3.1 Primary Research Question & Hypotheses………………………………..….pp.159 3.2 Secondary Research Questions………………………………………………..pp.161 Chapter 4: Palaeopathology & Previous Bioarchaeological Research………………....pp.162 4.1 Palaeopathology of EA Classification: Lumpers & Splitters ………………...pp.162 4.2 Palaeopathology of Reactive Arthropathies: The Common Rendition….....pp.165 4.3 SpA Research in Bioarchaeology……………………………………….….….pp.169 4.4 Military Assemblage Research in Bioarchaeology…………………………...pp.174 4.5 Summary on Project Placement………………………………………………..pp.179 [4] MATERIALS & METHODS CHAPTERS Chapter 5: Materials………………………………………………………………………………pp.180 5.1 Assemblage Selection…………………………………………………………...pp.178 5.2 Background on Selected Assemblages………………………………………..pp.185 5.2.1 All Saint’s Church………………………………………………………pp.185 5.2.2 Chelsea Old Church (OCU00)………………………………………..pp.187 5.2.3 St. Brides Lower (FAO90)…………………………………………….pp.189 5.2.4 Towton…………………………………………………………………..pp.191 5.2.5 York Mass Grave…………………………………………………...…pp. 197 5.2.6 Plymouth Royal Naval Hospital………………………………………pp.203 5.2.7 Greenwich Royal Naval Hospital……………………………………..pp.210 5.3 Summary on Assemblages……………………………………………………..pp.216 Chapter 6: Methods……………………………………………………………………………….pp.218 6.1 Methodology: Literature Investigation…………………………………………pp.218 6.2 Methodology: Skeletal Investigation…………………………………………..pp.221 6.2.1 Skeletal Recording………………………………………………….....pp.221 6.2.2 Pathology Identification & Classification …………………………....pp.222 6.2.3 Statistical Analysis……………………………………………………..pp.235 6.3 Examples of Case Classification……………………………………………….pp.243 6.3.1 Reactive Pathology Example…………………………………………pp.243 6.3.2 Unidentified Pathology Example………………………………...…...pp.246 6.3.3 Nonreactive Pathology Example……………………………………..pp.250 6.4 Summary of Methods……………………………………….…………………...pp.251 [5] RESULTS CHAPTERS Chapter 7: Results for the Literature Investigation…………………………………………pp.252 7.1 Summary of Utilized Primary Resources ...…………………………….…..…pp.253 7.2 General Medical References …………………...……………………………...pp.255 7.3 Retrospective Diagnosis of Reactive Arthropathy ………..………………….pp.261 7.4 Military Medical References…………………………………………………….pp.265 7.4.1 Direct Quotations of ReA……………………………………………...pp.265 7.4.2 ARF & ReA in Nineteenth Century Conflicts………………………..pp.272 7.5 Summary of Literature Results………………………………………….……...pp.275 7.6 Conclusions & Interpretations…………………………………………………..pp.278 Chapter 8: Results for the Skeletal Investigation………………………………………...…pp.280 8.1 Introduction ………………………………………………………………………pp.280 8.2 Prevalence Analysis………………………………………………………….….pp.282 8.2.1 Introduction……………………………………………...……….……..pp.282 8.2.2 Site Comparisons for Prevalence………………………………….…pp.285 8.2.3 Type Comparisons for Prevalence: Military vs. Non-Military……..pp.287 8.2.4 Prevalence Comparison with Previous Bioarchaeological Research………………………………………………………………pp.289 8.3 Nested Case Controls…………………………………………………………...pp.290 8.3.1. Introduction…………………………………………………………….pp.290 8.3.2 Reactive Pathology Nested Case Control Study…………………...pp.291 8.3.3 Reactive Suspect Pathology Nested Case Control Study…………pp.292 8.4 Results for Age Analysis………………………………………………………...pp.293 8.4.1 Introduction……………………………………………………………..pp.293 8.4.2 Greenwich & Plymouth Prevalence Comparison…………………..pp.295 8.4.3 Site Comparisons for Diagnosis Above & Below Age 35………….pp.296 [6] 8.4.4 Type & Total Comparisons for Diagnosis Above & Below Age 35: Military vs. Non-Military………………………………………………pp.298 8.5 Results for (N) Measures………………………………………………………..pp.300 8.5.1 Introduction …………………………………………………………….pp.300 8.5.2 Prevalence Differences between (N) Measures……………………pp.301 8.6 Results for Criteria Analysis…………………………………………………….pp.302 8.6.1 Introduction……………………………………………………………..pp.302 8.6.2 Numerical Accounting of Criteria……………………………………..pp.302 Chapter 9: Interpreting Skeletal Results……………………………………………………...pp.303 9.1 Interpreting Prevalence Results………………………………………………..pp.303 9.1.1 Site Comparisons for Prevalence…………………………………….pp.303 9.1.2 Type Comparisons for Prevalence: Military vs. Non-Military……..pp.305 9.1.3 Prevalence Comparison with Previous Bioarchaeological Research………………………………………………………………pp.310 9.2 Interpreting the Nested Case Control Results………………………………...pp.312 9.2.1 Reactive Pathology Nested Case Control…………………………..pp.312 9.2.2 Reactive Suspect Pathology Nested Case Control………………...pp.312 9.3 Conclusions on the Primary Research Question……………………………..pp.314 9.4 Interpreting Methodological Results…………………………………………...pp.316 9.4.1 Interpreting the Intrinsic Factor of Age………………………………pp.316 9.4.2 Interpreting the Results for (N) Measures…………………………..pp.318 9.4.3 Interpreting Criteria Results………………………………………......pp.319 9.4.4 Conclusions on Methodological Results…………………………….pp.320 9.5 Conclusions on Skeletal Results……………………………………………….pp.321 [7] Chapter 10: One Man’s Experience: A Case Study………………………………………….pp.322 10.1 Case Background.......................................................................................pp.322 10.2 Description of Skeletal Changes: Differential Diagnosis…………………...pp.326 10.3 Description